A Cross-Cultural Examination of Knowledge and Beliefs about Mental Disorders
Laura Altweck
Dissertation submitted for the degree of Doctor of Philosophy College of Health and Life Sciences
Brunel University
April 2016
Declaration
I hereby declare that this dissertation has not been and will not be submitted in whole or in part to another University for the award of any other degree. Some of the ideas, literature review (General Introduction) and results (Chapter 3) presented in this dissertation have been published:
Altweck, L., Marshall, T. C., Ferenczi, N., & Lefringhausen, K. (2015). Mental health literacy: a cross-cultural approach to knowledge and beliefs about depression, schizophrenia and generalized anxiety disorder. Frontiers in psychology, 6.
Other Publications
Altweck, L., & Marshall, T. C. (2015). When You have Lived in a Different Culture, Does Returning ‘Home’ not Feel like Home? Predictors of Psychological Readjustment to the Heritage Culture. PLOS ONE. doi: 10.1371/journal.pone.0124393
Reed, P., Altweck, L., Broomfield, L., Simpson, A., & McHugh, L. (2012). Effect of Observing-Response Procedures on Overselectivity in Individuals With Autism Spectrum Disorders. Focus on Autism and Other Developmental Disabilities, doi: 1088357612457986.
Presentations
Altweck, L., & Marshall, TC. (2014). Knowledge and beliefs about mental illness: a
cross-cultural comparison. 22
ndInternational Congress: International Association for Cross-
Cultural Psychology.
Acknowledgements
This dissertation would not have reached completion without the support, guidance and
encouragement of some key individuals. First, I would like to thank my supervisor, Dr. Tara
Marshall, who inspired me to start this journey, and without whose continuous guidance and
support I certainly would not have finished. I owe immense gratitude to my family who believed
in me, at times more than I did myself. I am especially thankful to Mama who was the rock that
grounded me when I needed encouragement and who was the first to know when things were
going well. Thank you, Mama, for reminding me to be true to myself and pushing me to be the
best I can be. I also want to thank Mycroft, Joe and Lorenzo, for their ceaseless emotional
support throughout the process and for giving me a push to continue when I needed it. Finally,
I would like to thank all of those individuals without whose participation this research would
not have been possible. I often gained more insight than I had expected, receiving anecdotes
and personal stories. I hope that the present research is a step along the way in encouraging
conversation about mental illness in a world where it is still considered taboo.
Abstract
How and why do the public’s knowledge and beliefs about mental disorders differ across cultures? Research has widely established that knowledge and beliefs about the symptoms, causes, treatments and stigma towards mental illness vary across cultures. However, few studies have examined the factors that may be associated with this variation. The overall purpose of the present dissertation was twofold: first, to cross-culturally validate measures of beliefs about mental disorders, and, second, to examine the influence of cultural variables with the aim of explaining cross-cultural variation. The General Introduction outlines the current research strands of knowledge and beliefs of mental disorders (namely, mental health literacy [MHL]
and mental illness stigma), describes the importance of examining culture and introduces its
framework, and describes how knowledge and beliefs differ cross-culturally. Further, cultural
variables (collectivism and its facets) and their possible role in determining cross-cultural
variation in MHL and mental illness stigma are introduced. The present research also examined
differences in beliefs between mental disorders (schizophrenia, depression, generalised anxiety
disorder [GAD]). Studies 1 and 2 revealed that across cultures MHL was better regarding
schizophrenia and depression than GAD. Study 1 further found that recognition of symptoms
of mental illness was greater in the Caucasian British sample compared to the South Asian and
African-Caribbean samples, which corroborated previous research. Study 2 tested the cross-
cultural equivalence of measures of causal and help-seeking beliefs, and cross-culturally
validated the MHL model in European Americans and Indians. Confirmatory factor analysis
(CFA) eliminated culturally non-equivalent items and therefore established a sound measure of
causal and help-seeking beliefs for mental disorders. Furthermore, structural equation
modelling (SEM) found good support for the MHL model cross-culturally, with recognition
being the best predictor of endorsing causal and help-seeking beliefs across cultures. However,
the significant cross-cultural difference in the model was that Indians, but not European
Americans, viewed lay help-seeking beliefs as vital in relation to treatment of mental illness.
The second part of Study 2 examined the relationship between MHL and mental illness stigma.
Associations between the two constructs were non-significant across cultures, however
implications are limited as only one aspect of mental illness stigma was measured. Study 3
cross-culturally validated a commonly-used measure of mental illness stigma and tested
equivalence of the mental illness stigma model in European Americans and Indians. As in Study
2, CFA indicated which culturally-equivalent items to retain, and SEM of the mental illness
stigma model established its applicability in both cultural groups. Finally, the second part of
Study 3 examined social and cultural variables in relation to mental illness stigma. The results
showed that classic religiosity, conformity to norms, familial support, honour and obligations
were significant predictors of stigma. It was particularly noteworthy that conformity to norms
significantly predicted lesser discrimination in the Indian sample, while endorsement of familial
obligations indirectly predicted greater discrimination through prejudicial beliefs in the
European American sample. The General Discussion evaluates the main findings, discusses
implications, limitations, and directions for future research.
Contents
1. General Introduction _______________________________________________________________________________ 1 1.1. Mental Health Literacy ____________________________________________________________________________ 3
1.1.1. Recognition ____________________________________________________________________________________ 3 1.1.2. Causal beliefs __________________________________________________________________________________ 5 1.1.3. Help-seeking beliefs ___________________________________________________________________________ 7 1.1.4. Professional help-seeking beliefs ____________________________________________________________ 8 1.1.5. Lay help-seeking beliefs ______________________________________________________________________ 9 1.1.6. Summary _______________________________________________________________________________________ 9
1.2. Mental Illness Stigma _____________________________________________________________________________ 101.2.1. Definition and Conceptualisation ___________________________________________________________ 12 1.2.2. Stigmatising beliefs___________________________________________________________________________ 14 1.2.3. Dimensions of mental illness stigma ________________________________________________________ 15 1.2.4. Socio-demographic variables as predictors of mental illness stigma ____________________ 17 1.2.5. Summary ______________________________________________________________________________________ 19
1.3. Culture _____________________________________________________________________________________________ 191.3.1. History of and beliefs about mental illness across cultures _______________________________ 21 1.3.2. Culture: concept and definition _____________________________________________________________ 23 1.3.3. Collectivism ___________________________________________________________________________________ 29 1.3.4. Summary ______________________________________________________________________________________ 31
1.4. Mental Health Literacy and Culture _____________________________________________________________ 321.4.1. Recognition ___________________________________________________________________________________ 33
1.4.2. Causal beliefs _________________________________________________________________________________ 34
1.4.3. Professional help-seeking beliefs ___________________________________________________________ 35
1.4.4. Lay help-seeking beliefs _____________________________________________________________________ 36
1.4.5. Summary ______________________________________________________________________________________ 37
1.5. Mental Illness Stigma and Culture _______________________________________________________________ 381.5.1. Cultural variation in authoritarianism, benevolence, community mental health ideology and social distance __________________________________________________________________________________ 40 1.5.2. Summary ______________________________________________________________________________________ 42
1.6. Research Overview ________________________________________________________________________________ 422. Mental Health Literacy in Caucasian British, African-Caribbean and South Asian samples in the UK ________________________________________________________________________________________________ 46
2.1.1. Mental Disorders _____________________________________________________________________________ 46
2.1.1.1. Schizophrenia ________________________________________________________________ 47 2.1.1.2. Depression ___________________________________________________________________ 54 2.1.1.3. Generalised Anxiety Disorder ____________________________________________________ 56 2.1.1.4. Comparison of mental disorders __________________________________________________ 582.1.2. Ethnicity _______________________________________________________________________________________ 59
2.2. Method ____________________________________________________________________________________________ 642.2.1. Ethics Statement ______________________________________________________________________________ 64 2.2.2. Participants ___________________________________________________________________________________ 64 2.2.3. Procedure _____________________________________________________________________________________ 65 2.2.4. Measures ______________________________________________________________________________________ 66
2.2.4.1. Vignettes ____________________________________________________________________ 66 2.2.4.2. Recognition __________________________________________________________________ 66 2.2.4.3. Causal and Help-Seeking Beliefs __________________________________________________ 66 2.2.4.3.1. Causal beliefs categories _______________________________________________________ 69 2.2.4.3.2. Help-seeking beliefs categories _________________________________________________ 73 2.2.4.4. Socio-demographic variables _____________________________________________________ 75 2.3. Results _____________________________________________________________________________________________ 762.3.1. Hypotheses 1.1 & 2.1: Recognition __________________________________________________________ 76
2.3.2. Hypotheses 1.2.a & 2.2a: Causal beliefs _____________________________________________________ 77
2.3.3. Hypothesis 1.2.b: Help-seeking beliefs _____________________________________________________ 78
2.4. Discussion _________________________________________________________________________________________ 812.4.1. Mental disorders in relation to MHL ________________________________________________________ 81 2.4.2. Ethnicity in relation to MHL _________________________________________________________________ 82 2.4.3. Strengths, limitations and future directions _______________________________________________ 84 2.4.4. Conclusion ____________________________________________________________________________________ 86
3. The Mental Health Literacy Model and Collectivism _________________________________________ 883.1.1. European Americans versus Indians _______________________________________________________ 88 3.1.2. Hypotheses ___________________________________________________________________________________ 90
3.2. Method ____________________________________________________________________________________________ 983.2.1. Ethics Statement ______________________________________________________________________________ 98 3.2.2. Participants and Procedure__________________________________________________________________ 98 3.2.3. Measures ______________________________________________________________________________________ 99 3.2.3.1. Collectivism _________________________________________________________________________________ 99 3.2.3.2. MHL measures ____________________________________________________________________________ 100 3.2.4. Data Analysis _______________________________________________________________________________ 101
3.3. Results ____________________________________________________________________________________________ 1083.3.1. Hypothesis 1(a): validating the professional help-seeking beliefs measure ___________ 108 3.3.2. Hypothesis 1(b): validating the lay help-seeking beliefs measure _____________________ 114 3.3.3. Hypothesis 1(c): validating the causal beliefs measure _________________________________ 115 3.3.4. Hypotheses 2, 3, 5, 6, 8: model testing ____________________________________________________ 119 3.3.5. Hypotheses 4, 7 and 9: indirect effects ___________________________________________________ 123
3.4. Discussion ________________________________________________________________________________________ 1253.4.1. Causal beliefs, professional help-seeking beliefs and lay help-seeking beliefs measures
______________________________________________________________________________________________________ 125
3.4.2. Mental Disorders ___________________________________________________________________________ 127
3.4.3. MHL Model __________________________________________________________________________________ 127
3.4.4. Strengths, limitations, and future directions _____________________________________________ 130
3.4.5. Conclusion __________________________________________________________________________________ 131
4. The Mental Health Literacy Model, Collectivism and Mental Illness Stigma ____________ 132
4.1.1. Collectivism and mental illness stigma ___________________________________________________ 133 4.1.2. Hypotheses _________________________________________________________________________________ 134
4.2. Method ___________________________________________________________________________________________ 136 4.3. Results ____________________________________________________________________________________________ 137 4.4. Discussion ________________________________________________________________________________________ 1394.4.1. Conclusion __________________________________________________________________________________ 141
5. The Mental Illness Stigma model ______________________________________________________________ 1425.1.1. Community Attitudes toward the Mentally Ill (CAMI) measure ________________________ 142 5.1.2. Mental Illness Stigma Model _______________________________________________________________ 144
5.2. Method ___________________________________________________________________________________________ 1475.2.1. Ethics Statement ____________________________________________________________________________ 147 5.2.2. Participants _________________________________________________________________________________ 147 5.2.3. Procedure ___________________________________________________________________________________ 147 5.2.4. Measures ____________________________________________________________________________________ 147 5.2.5. Data Analysis _______________________________________________________________________________ 149
5.3. Results ____________________________________________________________________________________________ 1495.3.1. Hypothesis 1: Measure validation. ________________________________________________________ 149 5.3.2. Hypothesis 2: Cross-cultural validation of the Mental Illness Stigma Model. __________ 155
5.4. Discussion ________________________________________________________________________________________ 1585.4.1. CAMI measure validation __________________________________________________________________ 159
5.4.2. Mental illness stigma model validation ___________________________________________________ 162
5.4.3. Strengths and limitations __________________________________________________________________ 162
5.4.4. Conclusion __________________________________________________________________________________ 163
6. The Mental Illness Stigma Model and Predictor Variables ________________________________ 1646.1.1. Collectivism _________________________________________________________________________________ 164
6.1.2. Conformity to norms _______________________________________________________________________ 165
6.1.3. Familial Support ____________________________________________________________________________ 167 6.1.4. Family honour ______________________________________________________________________________ 168 6.1.5. Familial obligations ________________________________________________________________________ 170 6.1.6. Religiosity ___________________________________________________________________________________ 172 6.1.7. Hypotheses _________________________________________________________________________________ 173
6.2. Method ___________________________________________________________________________________________ 1756.2.1. Conformity to norms _______________________________________________________________________ 176 6.2.2. Familial support ____________________________________________________________________________ 176 6.2.3. Family honour ______________________________________________________________________________ 176 6.2.4. Familial obligations ________________________________________________________________________ 177 6.2.5. Religiosity ___________________________________________________________________________________ 177
6.3. Results ____________________________________________________________________________________________ 1786.3.1. Hypotheses 3 and 4: Indirect effects ______________________________________________________ 181
6.4. Discussion ________________________________________________________________________________________ 1836.4.1. Family honour ______________________________________________________________________________ 183 6.4.2. Familial obligations and support __________________________________________________________ 184 6.4.3. Conformity to norms _______________________________________________________________________ 185 6.4.4. Religiosity ___________________________________________________________________________________ 186 6.4.5. Strengths, limitations, and future directions _____________________________________________ 187 6.4.6. Conclusion __________________________________________________________________________________ 188
7. General Discussion _______________________________________________________________________________ 189 7.1. Variation across mental disorders ______________________________________________________________ 189 7.2. Variation across cultures ________________________________________________________________________ 190 7.3. Mental health literacy and mental illness stigma models across cultures ____________________ 1937.3.1. Mental Health Literacy model _____________________________________________________________ 194
7.3.2. Mental illness stigma model _______________________________________________________________ 195
7.4. Variables that predict knowledge and beliefs about mental illness ___________________________ 1957.4.1. Collectivism _________________________________________________________________________________ 195 7.4.2. Conformity to norms, familial support, honour and obligations _______________________ 197 7.4.3. Religiosity ___________________________________________________________________________________ 199
7.5. Implications ______________________________________________________________________________________ 200 7.6. Limitations and future directions _______________________________________________________________ 202 7.7. Final remarks ____________________________________________________________________________________ 2058. References _________________________________________________________________________________________ 207 9. Appendix __________________________________________________________________________________________ 250