Stigma of mental illness and cultural factors in Pacific Rim region: a systematic review

The following electronic databases were searched through January 2003 to April 2019: MEDLINE, Embase, CINAHL, Web of Science, PsycINFO, Scopus, Cochrane Library and Google scholar. Additionally, we checked reference lists of relevant articles and ran a search of relevant studies individually. The following keywords were used on screening titles and abstracts: (“mental illness” OR “mental disorders” OR “psychiatric disorders” OR “common mental disorders” OR “mental health”) AND (“stigma” OR “discrimination” OR “prejudice” OR “stereotype”) AND (“cultural values” OR “cultural beliefs” OR “face” OR “cultural characteristics”). The review was pre-registered at the PROSPERO (CRD42020138108). We have followed PRISMA reporting guidelines.

The reviewers (TMZ & XHL) screened and evaluated each title and abstract to identify relevant articles. Citations and abstracts were imported into Endnote X9. If a study was identified as relevant to the review, the reviewers accessed the full text article. English articles that were published and peer-reviewed were considered for this review. Studies were not restricted to a certain group of participants, stigma type, cultural factor, outcome and study design. However, if comparisons were conducted, it is necessary to demonstrate sufficient statistics. An article was selected for inclusion if it met all of the following criteria: 1) to be related to stigma of mental illness; 2) in the Pacific Rim; and 3) addressed culture factor. We employed a cautiously analysis to access the risk of bias using the Critical Appraisal Skills Program (CASP). The reviewers recorded “yes”, “no” or “can’t tell” in each question of appraisal checklists [15, 16]. In addition, a pilot assessment on 5 articles was undertaken separately by two reviewers to check the consistency, then we started the formal analysis. Studies were judged independently by two reviewers (TMZ & XHL) and those with an unacceptable risk of bias were excluded. Disagreements and uncertainties were discussed until reviewers reached consensus with a senior reviewer (MSR).

After identifying studies for inclusion, reviewers extracted relevant data and developed a set of data extraction categories: (1) overview of stigma type, cultural values; (2) study characteristics including author, year, location of study (country), study type, stigma type, target population, measurements, salient cultural values and main findings. Additionally, the rates of stigma (e.g., self stigma and public stigma) reported in the results within quantitative studies were extracted directly for further analysis. After summarizing the results in the data extraction table, the reviewers extracted the data through a data collection tool that was developed by MSR and summarized the results into five broad categories by consensus of all reviewers, as follows: 1) cultural factors: cultural factors affecting stigma of mental illness, such as causal attributions, religion, value orientation, cultural norms, and beliefs; 2) stigma categories: stigma framework of Corrigan and Watson [1], by adding the other two types; 3) anti-stigma interventions: being categorized according to socio-ecological levels; 4) measurements: scales employed; and 5) rates of stigma: being extracted or calculated to generate the final number.

Figure 1 shows the procedure of the review. The initial database search obtained 1490 published English-language articles after removing duplicates. The next stage of study selection involved a manuscript review of 88 articles. Some articles were excluded as they were not peer-reviewed (n = 9), not related to mental health stigma (n = 10), not in Pacific Rim (n = 9), not related to culture (n = 4), not full text available (n = 15). Articles that substantiating pilot assessment were also included. A total of 41 studies were included in the final review.

Table 1 shows the characteristics of reviewed studies. A total of 41 studies were identified, including 14 qualitative only studies, 19 quantitative only studies, 3 mixed-method studies and 5 theory studies. Among these, 13 studies were undertaken in the USA, 18 in Asia and 3 in Latin America. In addition, 5 studies were carried out across more than one continent. There were 3 studies focusing on intellectual disabilities specifically, 1 study on bipolar disorder, 1 study on substance use, 3 studies on depression, and 6 studies on schizophrenia. The majority of these studies focused on mental health and mental illness in general. 5 studies specifically targeted youths and students. 1 study had a teacher focus and 3 studies concerned mental health providers, the remaining concentrated on adults or non-specified job groups. Regarding types of stigma, 20 studies included public stigma, 13 studies involved self-stigma, 10 studies involved affiliate stigma and only 2 studies focused on professional stigma. Nine studies reported rates of stigma. Across all the studies included in the final review, specific intervention was poorly conducted, but many studies attempt to present the intervention and policy suggestion for alleviating stigma. Viewing the cultural factors, apart from 1 study interpreting multiple cultural factors, supernature beliefs and religion were reported on 9 studies, followed by face concern and familism reported on 29 studies, collectivism and Confucianism were reported by 8 studies, 3 studies addressed individualism.

Regarding the risk of bias, the studies were categorized into the high, moderate and low risks. Although five of the studies were theory studies, in consideration of the purposes of providing a wide review on the topic, they were included in the final review. As a result, all studies were considered to display an acceptable risk of bias.

There were four types of stigma of mental illness as following: public stigma, self-stigma, affiliate stigma and professional stigma.

According to the results of studies reviewed [12, 19, 23, 34, 39, 51], persons with mental illness usually were labelled as dangerous, weak, strange, incompetent and blameworthy. The perception that persons with mental illness behave violently was considered as a major reason for general public displaying stigmatizing behaviors and attitudes toward persons with mental illness. Due to exposure to prevalent public stigma, a substantial number of persons with mental illness encountered isolation, rejection and social distance from society, friends, families, and partners [39]. Stigma from close individuals, such as relatives and friends were more hurtful than that of general public [50]. Furthermore, stigmatizing beliefs and stigmatizing actions might deter help seeking and treatment, which is associated with symptom deterioration [12]. Additionally, Abdullah and Brown (2011) [11] summarized that cultural values related to social image, such as marianismo (that females should be self-sacrificing) and machismo (that males should be strong) in Latino values, also caused public stigma for persons with mental illness. Such kinds of social image also appeared in Indian culture, where the homemaker role keeps them from social support and resulted in fear of social rejection [23]. Two studies demonstrated that public stigma toward persons with mental illness might be more severe in non-Western cultures [12, 34]. A comparative study [22] summarized that although both Japanese and Australian public perceived persons with mental illness as dangerous and unpredictable, Japanese public also strongly believed that mental illness involved in personal weakness. Notably, Yang and Kleiman (2008) [52] conceived that stigma was a moral issue and “face” constructed by moral standing played an important role in Chinese societies. As a result, the moral status of persons with mental illness might be lower and they had higher difficulties accessing social capital due to loss of face.

13 studies [2, 18, 22, 24, 33, 35, 36, 38, 41, 42, 46, 47, 51] addressed self-stigma of persons with mental illness. Evidence suggested that self-stigma regarding mental health was associated with lower level of self-esteem, which in turn resulted in negative outcomes [41]. Two studies [35, 38] indicated that stigma of mental illness might reduce the social networks of persons with mental illness considerably. In particularly, evidence demonstrated that face concern was strongly associated with self-stigma [18, 36]. In a study from Chile [41], the manifestation of stigma was influenced by the role of family and social status. In short, research provides substantial evidence that cultural values may play significant roles in stigma internalization.

Results from 10 studies [17, 20, 21, 26, 40, 45, 48, 49, 51, 54] demonstrated that mental illness stigma did not just affect those with mental illness, but also influenced their family caregivers [17]. Apart from economic and caregiving burden, family caregivers themselves often experienced poor mental health [45]. Affiliate stigma, the stigma felt due to the mental health or disability of a loved one, contributed to this burden. Caregivers might have cognitive and behavioral reactions including social withdrawal, self-compassion, overprotection, perceptions of lower competence and worth than their peers, and feelings of shame and embarrassment [20, 21, 40, 48, 54].

Stigma also affects mental health professionals, such as psychiatrists, menta health counselors, social workers and nurses due to having a connection with persons with mental illness. An occupational hazard for mental health professionals working with those with mental illness might include experienced stigma from the public, i.e., professional stigma or associative stigma, which might also lead to professionals enacting stigma against their clients or holding negative attitudes toward their clients [27, 37]. Luo et al. (2018) [37] reflected that apart from fear of violent behavior of persons with mental illness, loss of face was another major concern for professionals that working in underdeveloped psychiatric facilities with negligent care made them feel shame and engage in lower social status. Mental health professionals might exhibit significantly different levels of social acceptance toward persons with mental illness in various sociocultural contexts.

Table 2 shows the rates of self stigma and public stigma toward mental illness in Pacific Rim region. Overall, the rate of stigma of mental illness in Pacific Rim region was relatively high (e.g., self stigma in persons with mental illness: from 15 to 94.7%; public stigma: from 25.4 to 85.2%), especially in China and the USA. It could be expressed by the influence of various sociocultural contexts.

Table 3 shows the main findings of cultural factors in the reviewed studies. The major cultural factors or values were illustrated as following.

Confucian and Collectivist values were examined by several studies. Abdullah and Brown (2011) [11] demonstrated that many East Asian cultures were deeply rooted in collectivist and Confucian values, which emphasize harmonious social relationship and solidarity, especially in Chinese, Japanese and Korean communities. Individuals were required to adhere to the norm and those with inappropriate behavior were often disparaged publicly in these communities [28, 37]. In general, mental illness is considered a strain on collective systems within Asia, including families, social groups and society as a whole because of the common stereotypes that persons with mental illness are strange, dangerous, unpredictable and out of control. Many Asians might display stigmatizing behavior toward persons with mental illness, such as declining to hire them [34, 39]. Pang et al. (2017) [28] found that Chinese youths with mental illness suffered from more physical threat and higher level of social distance due to influence of collectivism. Even in some Asian countries, individuals with mental illness might be viewed as representing the family’s mental illness, bad blood, or past misdeeds [11, 17, 29, 52, 53].

Apart from Asian societies, Latino Americans, Native Americans and African Americans also engaged in collectivism and cooperation [42, 47], which is contradictory to Caucasian Americans that mainly value individualism. In contrast, Caucasian people might be less likely to pay attention to whether individuals have harmonious relationships. For example, compared with their counterpart in China, Caucasian American employers concerned more whether their employees had the required skills to finish the job rather than placing value on social relationships [34]. This might be that Caucasian Americans tend to consider mental illness as an individual experience in nature [47]. Consequently, Caucasian American employees might suffer from less stigma [34].

Face concern, which refers to individuals’ desire to maintain their social image, social values and social capitals influenced by their performance and specific social roles, has been well documented in collective societies [21]. Yang and Kleinman (2008) [52] illustrated the stigma regarding moral experience in China. Generally, face concern in Chinese culture consists of two dimensions: lian (moral worth) and mianzi (social values) in Chinese culture [17, 18]. Face concern is associated with the feeling of shame and internalization of stigma. Persons with mental illness and their families in some Asian communities, such as Chinese, Korean, Japanese and Vietnamese, tended to avoid disclosure of mental illness in order to save face, which might lead to delayed treatment seeking. This might be because they held the belief that maintaining a respectable standing in their social network was essential [39, 53], and mental illness was associated with poor moral character, spiritual issues, or family issues [36, 45, 52]. Furthermore, loss of face might result in several negative consequences, such as being classified as an outcast and having difficulties maintaining a good reputation [18]. In the cultural context of Latin America, persons with mental illness might feel that they were not worthy of dignity and respect, which is linked to the process of self-stigma [11]. With respect to public stigma, it was found that the general public concerns whether interactions with persons with mental illness might lead to a loss of face [37].

Given that persons with mental illness were commonly regarded as a shame or guilt to the whole family among Chinese, Korean, Japanese and Latino, family caregivers with strong face concern might also experience heightened psychological stress [21]. Some chose to seek support from family instead of seeking formal medical treatment [36, 46]. Japanese family caregivers even resisted persons with mental illness interacting with people outside the family. Interian et al. (2007) [43] found that Latinos with family-orientation had a greater likelihood of refusing diagnosis and treatment. In the context of Latin American, the traditional gender value “machismo” contextualized within the framework of the culture known as familism also played a powerful role in shaping stigma of mental illness, given that machismo states male’ ability to protect family honor, and the female’s ability to be a proper and pure mother, while suffering from mental illness is considered as failing to fulfill their family obligation [51].

The importance of the link between genetics and mental illness might lead to parents and family members disapproving of marriage with persons suffering mental illness [35, 37, 52]. Compared with European Americans, Chinese Americans paid more attention on heredity of mental illness [19]. Actually, evidence in relation to familism also showed that African Americans considered mental illness as a family’s failure to tackle the issue [42].

Face concern and familism play significant roles in stigma of mental illness in collective cultures of the Pacific Rim region. Yang et al. (2007) [53] also explored the moral values in American cultures, but did not provide adequate support that stigma possess a moral dimension within European and North American traditions. Further studies should be conducted in this area.

Although Western treatment methods for mental illness, such as medication, were considerably widespread in Asian and Latin American societies, supernatural factors, including traditional and folk religion were still endorsed in Vietnam, India, China and Latin districts, especially in rural areas [12]. Many people strongly believed that mental illness involved evil spirits, fate, punishment prompted by God, ancestors or dead souls [34, 35, 45]. Abdullah and Brown (2011) [11] also reported that many Asian Americans might be more likely to believe that mental illness is a punishment caused by God due to previously bad behavior. For example, Vietnamese Buddhists believed the cause of mental illness lied in “karma”, such that persons with mental illness must had done bad things in their past life [45]. Many Chinese people considered that possible reasons of mental illness might be related to problems of ancestor’s tomb [2].

Latino Americans who engaged in Catholicism conceptualized mental illness as resulting from lack of faith, without praying and devil occupying mind, or demons [44]. They pervasively attributed ill to God’s will, suggesting the presence of fatalistic views [30]. Many persons with mental illness consequently visited spiritual healers or temples for their initial consultation regarding a possible mental health concern [12, 28, 44].

Abdullah and Brown (2011) [11] concluded that most research regarding stigma of mental illness in the USA used the samples of Caucasians who influenced by European background and values. The most significant value of that was individualism and competition which rooted in independence, autonomy and individual success. In line with others ethnic groups, stigma of mental illness also deterred Caucasian with mental illness from treatment [11, 22], which might be explained by their concern for individual success and constant comparison to the others. Papadopoulos et al. (2013) [32] compared the difference regarding stigma among four cultural groups, including a White-English group, a Greek Cypriot group, a Chinese group and an American group, indicating that individualism which affecting American group profoundly was associated with less stigmatizing attitudes towards mental illness. One possible mechanism was that individualist cultures was highly relevant to tolerate diversity and deviation from social norms. Apart from that, mental illness was described as an individual issue, especially amongst Caucasians [47].

There were numerous measurements to assess different type of cultural factors related to stigma of mental illness, such as Loss of Face Scale (LOF) [55] and Supernatural Attitudes Questionnaire (SAQ) [56] (Table 1). In a Chilean study [46], “culture-specific” module was considered to add in two significant stigma measures to construct a psychometrically validated tool. Given the fact that the meanings, practices, and outcomes of stigma of mental illness are varied across culture, it is necessary to obtain perspectives from different constituencies in order to fully understand how stigma affects within particular sociocultural context. Multiple methodologies, including ethnographic methods and other several supplemental methodologies, e.g., art-based research methods such as a community-based theatre [47] and poetry [57] might work effectively to address how to measure stigma of mental illness in specific contexts [53].

Yang et al. (2014) [49] conducted and evaluated a pilot anti-stigma intervention with 3 sessions including psychoeducation, countering experienced stigma and countering internalized stigma among Chinese caregivers with affiliate stigma. They pointed out that it was important to address cultural concern with flexibility during the process of implementing intervention whatever apply any advanced or effective model. Additionally, several studies provided suggestions to develop effective anti-stigma strategies. Ramli et al. (2016) [40] stated that the intervention should meet several requirements, including being community-based, carefully targeted, and culturally specific. Yang (2015) [48] and Chiu et al. (2015) [21] demonstrated the intervention could be conducted at three levels: personal/individual level, family/interpersonal level, and community/societal level. At the personal level, it was essential to alleviate self-stigma and reduce the burden for persons with mental illness and caregivers, as well as emphasize social functioning. Intervention such as “re-moralization” counseling could help restore the face and re-engage society [20, 21]. At the family/interpersonal level, positive communication, network-based interventions, and caregiving task sharing were effective [36, 38, 48]. Furthermore, a systematic and scientific health care system and welfare service provision toward persons with mental illness were crucial at the community/societal level, such as the Mental Health Act introduced in 2018 contributed to reducing stigma and protecting the rights of persons with mental illness in Philippines [35]. One of significant strategies was increasing public understanding of mental illness [35], which is consistent with other studies on developing psychoeducation programs [12, 38, 42]. Mass media might serve as an effective tool to shape public perception and attitudes toward mental illness [37]. However, there were no studies to explore the effectiveness, especially long-term effectiveness, of the enhancing contact with persons with mental illness on reducing stigma of mental illness. Further studies should be conducted in this important area.