The mediating effect of affective stigma between face concern and general mental health – The case of Chinese caregivers of children with intellectual disability

https://doi.org/10.1016/j.ridd.2014.10.024Get rights and content

Highlights

  • Cultural value alone does not determine poor mental health.

  • Structural equation models show that affective stigma and anxiety mediate the effect of face concern on the mental health.

  • Affective stigma and anxiety may increase one's stress level and lower one's coping competence.

  • Culturally relevant practice to be developed to (a) draw on the cultural values that may render protective and resilient function; (b) address the issue of psychological wound caused by stigma; (c) target at anxiety reduction so that intervention can be more effective.

Abstract

An earlier study revealed that the mental health of caregivers of children with intellectual disability is related to the affective dimension of affiliated stigma, loss of face and anxiety level. However, how cultural values such as face concern interplay with stigma remains largely unknown. This extended study goes further to test the mediating role of affective stigma on two slightly different pathway models between the face concern and the mental health outcome of 211 caregivers in two Chinese cities, against the required standards and procedure of being a mediator. The mediating effect of affective stigma is confirmed by meeting Baron and Kenny's required standards. Two viable path models are worked out: one model with anxiety as a co-mediating variable successfully accounts for 17% more of the variance on the outcome than another model without anxiety, explaining a total of 56% of the variance. This provides empirical evidence for the first time that cultural values such as face value do not influence directly one's mental health; but works through the experience of real stigma or anticipated stigma situations, to induce anxiety and worsen mental health. Practitioners may need to employ anti-stigma and anxiety reduction strategy in promoting better mental health and to explore cultural elements that can be tapped on for better coping.

Introduction

Latest literature consistently shows that stigma has far-reaching effects on both individuals with intellectual disabilities (ID) and their family caregivers (Bos et al., 2013, Crabtree, 2007b, Dehnavi et al., 2011, Elafrosa et al., 2013). The term “affiliate stigma” describes the phenomenon whereby family caregivers of stigmatized individuals internalize the public stigma and that causes negatively affective, cognitive and behavioral reactions (Mak and Cheung, 2008, Mak and Cheung, 2011). Affective reactions refer to the feelings of shame, embarrassment, and despair caused by internalized stigma, and in fact most studies on affiliate stigma have focused on the affective experience of family caregivers of people with ID. In a study among the South African mothers of children with ID, all the participants indicated they had been suffering from feelings of embarrassment, despair, isolation and psychological frustration (Ntswane & van Rhyn, 2007). Other studies had similar results (Crabtree, 2007a, Huang et al., 2012). Many mothers reported that they felt lonely, helpless, and unable to fully interact with others and integrate into their community because of the fear of rejection and ridicule by others (Edwardraj et al., 2010, Mirza et al., 2009).

The cognitive reactions refer to the perceptions of lowered worth and competence, when compared to peers, because of the internalization of the stigmatized status. Previous research suggests that family caregivers may also cognitively endorse the public stigma toward people with ID and regard such people as incompetent and having negative effects on others. Some caregivers of children with ID may even hold attitudes that are more prejudicial and show less tolerance toward other children with ID. They may refuse to let their children attend special schools, worrying that other children with ID would be bad examples for their own children (Crabtree, 2007a). Mothers of children with ID in Taiwan also feel that having a healthy child is their fundamental and moral duty, and reproduction is a second chance to make up for their own faults of having a child with ID (Huang et al., 2012).

Behavioral reactions refer to the behavioral reactions, including withdrawal and self-denigration. Phelan, Bromet and Link (1998) tested the relationship between stigma and coping strategies among 156 family members. They demonstrated that half of the participants tended to conceal the child's hospitalization, and many perceived avoidance by others to some degree. Similar results were also reported by Larson and Corrigan (2008), who found that attempts to conceal their family members’ disabilities were very common among caregivers because of the fear of rejection by others. Family members are often reluctant to disclose they have relatives with ID to their communities, because they may need to avoid unfriendly and even hostile reactions stemming from their neighbours’ lack of tolerance for individuals with disabilities (Power, 2008, Todd and Shearn, 1997).

Some studies in Chinese societies also contribute considerably to the research on affiliate stigma. Chang (2009) conducted interviews with 38 caregivers of children with ID, including mothers, fathers and siblings in Taiwan and discovered that mothers segregated themselves not only from the public (e.g. friends and community members) but also from their family members and even their own children with ID. Many mothers simply gave up seeking help and confined themselves at home (Edwardraj et al., 2010). Some began to reduce their contact with other family members once they had a baby with ID (Fazil, Bywaters, Ali, Wallace, & Singh, 2002).

Although stigmas share features across contexts, cultural and local settings may shape how stigma is felt and represented subjectively (Yang et al., 2007). Mak and Cheung (2011) suggested that affiliate stigma is culturally salient, especially in face cultures, Chiu, Yang, Wong, Li, and Li (2013) have demonstrated that affiliate stigma and face concern are predictors for caregivers’ mental health in mainland China. One's mental health situation is associated with affiliated stigma, loss of face and anxiety, and these three antecedents have accounted for more than half of the variance (55%) in GHQ scores of the subjects. However the exact relation between affiliate stigma and face concern has not been clear. Specifically, what is unclear is the exact interplay between stigma and face, and whether stigma mediates the effect of face concern on one's mental health. Therefore, there is a need to test the mediating effect of stigma, and to illustrate a transactional model of how individual psychology interacts with the individual's wider environment (culture), specifically for families with ID.

Face concern/value can be defined as one's desire to preserve and maintain one's social image and social values based on one's performance and specific social roles that are well recognized by others within the interpersonal context (Choi and Lee, 2002, Goffman, 1967, Hu, 1944, Mak and Chen, 2006). It represents a person's social position or prestige (Hu, 1944), the uppermost limit of one's dignity and social respectability (Cheng, 1986). According to face-negotiation theory, “face is tied to the emotional significance and estimated calculations that we attach to our own social self-worth and the social self-worth of others” (Ting-Toomey, 2005, p. 73). On the affective level, when someone feels one's own face is threatened or risks losing face, an emotional response of some degree including fear and anxiety will be elicited. On a cognitive level, a face threat is measured according to the degree of how far the threatening action diverges from the cultural norms and values of behavior. The degree of divergence from normative behavior may lead to different face-related behavior referring to the communication skills one uses to save, uphold and manage face (Ting-Toomey, 1985). People with higher levels of face concern are more likely to restrict their behavior in keeping with the established social norms and attempt to fulfill the social expectations of their roles, and this may consume people's emotional well-being in daily life (Ting-Toomey & Kurogi, 1998). When people fail to maintain their face and perceive an uncertain or ambiguous self-image, their preoccupation with face may become increasingly problematic to their emotional well-being and mental health (Ho, 1991, Mak and Chen, 2006, Mak et al., 2009). Therefore, similar to other studies, our analytical framework proposes the hypothesis that face concern is negatively associated with mental health for the family caregivers of people with ID in mainland China.

To a large extent, face represents one's relation with society, and therefore may be closely associated with how public attitudes and the internalization of them work in Chinese society. Because collective representations related to cultural stereotypes have been identified to predate self-stigmatization (Major and O’Brien, 2005, Mak and Cheung, 2008), affiliate stigma will be culturally salient among Chinese people, given the moralization of beliefs around ID, such as a violation of moral principles and the value of interpersonal connections (Chiu et al., 2013). People who highly value face tend to define themselves according to the external or social norms and endorse these norms (Choi and Lee, 2002, Hwang, 1997). People with ID are commonly viewed as a shame to the whole family (Chen and Shu, 2012, Li, 2004). In addition to the fact that there is someone who is generally less competent in the kinship, ID may imply a contamination of their biological roots and a lowering of the genetic value of the family and the kinship. Therefore, family members who are highly concerned about face may be more ready to perceive and internalize public stigma and derogatory aetiological beliefs about disabilities and illnesses in the Chinese society (Mak and Kwok, 2010, Yang, 2007).

In particular, the present study focused on the key dimension of affiliate stigma, self-stigmatization, in its relationship with face culture. Face concern may particularly influence the emotions of shame and embarrassment in the process of stigma internalization (Ho et al., 2004, Lau et al., 1997), since Chinese social connections and social life are intertwined with the affective dynamic of face (e.g. renqing—human feelings) in daily interactions. In Chinese societies, the loss of social reputation and the weakening of interpersonal connections and social networking that result from stigma become inseparable from senses of overwhelming embarrassment, humiliation and despair (Yang & Kleinman, 2008). As Ho et al. (2004) suggested, the feelings of shame, embarrassment, isolation, and guilt often come from the perceived rejected self, which can be activated by a loss of face. It is because this self-rejection depends upon the internalization of the social norms, and individuals’ compliance with external demands. In the empirical study, Lau and colleagues (1997) asked four groups of participants to report their recent experiences that could be described as one of the following classifications: loss of face, near loss of face, embarrassment, and near embarrassment. Their results indicated that people who perceive a greater face threat were more likely to report a sense of embarrassment.

In addition, according to studies of social cognition and the dual-process model (Chaiken & Trope, 1999), the immediate reaction of people toward an event is often automatic, intuitive, and emotional, and this affective response is influenced by cultural stereotypes and social beliefs. Thus, affective reactions can be pre-cognitive without extensive perceptual and cognitive encoding, and can be made sooner and with greater confidence than cognitive judgments (Lerner and Keltner, 2000, Zajonc, 1980). The term “affect” can be taken to indicate an instinctual reaction to stimulation occurring before the typical cognitive processes considered necessary for the formation of a more complex emotion (Zajonc, 1980). The second process of reaction is reasoned and cognition and needs time to process and can be controlled and adjusted by increased knowledge, motivation, and attribution (Bargh and Chartrand, 1999, Fazio, 1986, Gawronski and Bodenhausen, 2006). Therefore, it is rational to hypothesize that cultural belief may particularly induce negative self-feelings which can further harm mental health.

Given the ample evidence of a link between face concern and personal ill-being in the literature, we chose the GHQ score as a proxy variable of personal distress, and face concern as an independent variable. We also chose affective stigma (i.e. feelings of self-stigmatization), and anxiety as independent but mediating factors, given their possible direct and indirect effect on the way a person copes with personal distress. It is hypothesized that face concern may have affective reaction in the face of affective stigma, because the concern over one's self-image in others’ eyes will facilitate the perception and endorsement of public stigma and thereby automatically and immediately induce feelings of shame. On the other hand, because of this mediating effect, we wonder if face concern may have limited effects on mental health, because affiliate stigma may invoke cognitive and behavioral reactions and coping. The path model will also provide clues as to whether the feelings of self-stigmatization will intensify their anxiety state, and adversely affect personal mental health and cause feelings of distress.

Section snippets

Statistical analysis

As the aim of this study is to investigate the potential mediating factors between face concern and mental health status, the method described by Baron and Kenny for identifying mediators was adopted (Baron and Kenny, 1986, Frazier et al., 2004). The requirements for confirming mediating effects are summarized as follows: (1) the predictor is related to the outcome; (2) the predictor is related to the mediator; (3) the mediator is related to the outcome variable; and (4) the strength of the

Results

Table 2 displays the correlation coefficients between the scores under different scale measurements in this study. Result shows that LOF was significantly correlated with GHQ with a Pearson correlation of 0.297 (p < 0.01). This means the requirement of the predictor (LOF) being related to the outcome (GHQ) is fulfilled (requirement 1). However, that FES was not significantly correlated with LOF implies that FES is not a mediator. This is because the predictor (LOF) has to be related to the

Discussion

In this study, cultural factors such as face concern do not appear to be a determinant for the mental health of caregivers. First, in terms of its magnitude of direct influence as well as indirect influence, face concern does not influence one's mental health outcome as strongly as affiliate stigma. Second, the mediating effect of affective stigma is able to explain more of the variance with the presence of the anxiety variable. It is conceivable that stigma can influence one's mental health

Limitations

There are a few limitations of this study. First, the study sample was collected from two cities in central China. The results may not be generalizable for the whole country. Second, this study was conducted in urban areas, whereas the culture in rural areas is more diverse and complex. The cultural diversity of districts, region and ethnicity may pose another difficulty to generalization. Third, the cross-sectional nature of the study does not provide longitudinal data and information on

Conclusion

This extended quantitative study points out the complexity of person-environment interactions in the understanding of one specific cultural element – face, in relation to affective stigma and the general mental health of caregivers. From the findings, we have articulated that the loss of face has a role to play in causing caregivers stress, yet at the same time our findings do not support the claim that cultural issue alone is decisive. The mediating effect of stigma should not be overlooked.

References (58)

  • R.M. Baron et al.

    The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations

    Journal of Personality & Social Psychology

    (1986)
  • A.E.R. Bos et al.

    Stigma: Advances in theory and research

    Basic and Applied Social Psychology

    (2013)
  • H.H. Chang

    From housewives to activists: Lived experiences of mothers for disability rights in Taiwan

    Asian Journal of Women's studies

    (2009)
  • C.H. Chen et al.

    The process of perceiving stigmatisation: Perspectives from Taiwanese young people with intellectual disability

    Journal of Applied Research in Intellectual Disability

    (2012)
  • C.Y. Cheng

    The concept of face and its Confucian roots

    Journal of Chinese Philosophy

    (1986)
  • M.Y.L. Chiu et al.

    Caregiving of children with intellectual disabilities in Mainland China – An examination of affiliate stigma and the cultural thesis

    Journal of Intellectual Disability Research

    (2013)
  • S.C. Choi et al.

    Two-component model of chemyon-oriented behaviors in Korea: Constructive and defensive chemyon

    Journal of Cross-Cultural Psychology

    (2002)
  • S.A. Crabtree

    Family responses to the social exclusion of children with developmental disabilities in the United Arab Emirates

    Disability & Society

    (2007)
  • S.A. Crabtree

    Maternal perceptions of care-giving of children with developmental disabilities in the United Arab Emirates

    Journal of Applied Research in Intellectual Disability

    (2007)
  • S.R. Dehnavi et al.

    The share of internalized stigma and autism quotient in predicting the mental health of mothers with autism children in Iran

    International Journal of Business and Social Science

    (2011)
  • S. Edwardraj et al.

    Perceptions about intellectual disability: A qualitative study from Vellore, South India

    Journal of Intellectual Disability Research

    (2010)
  • M.A. Elafrosa et al.

    Stigma and psychiatric morbidity among mothers of children with epilepsy in Zambia

    International Health

    (2013)
  • Q. Fazil et al.

    Disadvantage and discrimination compounded: The experience of Pakistani and Bangladeshi parents of disabled children in the UK

    Disability & Society

    (2002)
  • R.H. Fazio

    How do attitudes guide behavior?

  • P.A. Fazier et al.

    Testing moderator and mediator effects in counseling psychology research

    Journal of Counseling Psychology

    (2004)
  • B. Gawronski et al.

    Associative and propositional processes in evaluation: An integrative review of implicit and explicit attitude change

    Psychological Bulletin

    (2006)
  • E. Goffman

    Interaction ritual: Essays in face-to-face behavior

    (1967)
  • D. Goldberg

    A user's guide to the general health questionnaire/David Goldberg and Paul Williams

    (1988)
  • Cited by (35)

    • Perceived stigma and discrimination among persons with mood and anxiety disorders: Results from the WHO World Mental Health Survey Portugal

      2022, European Journal of Psychiatry
      Citation Excerpt :

      The influence of collectivist values on stigma have been well studied among Asians, Native American and Latin American cultures. While the desire to ‘save face’ is strongly associated with internalization of stigma in Asian cultures,28 failure to fulfil family obligations was linked to self-stigma among Latinos,29 who are culturally similar to the Portuguese. Although mental health has not received much attention in Portugal in the past, deinstitutionalization and mental health service reform have been ongoing since the country's national mental health strategy was launched in 2008.

    • Stigma experienced by families of individuals with intellectual disabilities and autism: A systematic review

      2019, Research in Developmental Disabilities
      Citation Excerpt :

      On a more practical side, given the comorbidity of challenging behaviours among individuals with ID and ASD in particular, parents should have access to behavioural management strategies. Given that affiliate stigma can affect one without conscious awareness (Chiu et al., 2015), the identification of parents susceptible through recognition of risk factors for affiliate stigma is critical. Offering culturally sensitive counselling and psychotherapy services to families deemed at risk of affiliate stigma and establishing peer support groups for them to provide emotional support through the exchange of shared experiences and reflections could serve as important early intervention strategies.

    View all citing articles on Scopus
    View full text