Stigma Toward Mental Illness

Abstract

This study investigated the relationship between culture and attitudes toward mental illness. In total, 196 men and 347 women were recruited from Australia and Taiwan. All participants completed a questionnaire assessing their attitudes toward mental illness. Australian-born Chinese and Chinese immigrants to Australia also completed a questionnaire assessing cultural values. Chinese immigrants to Australia and Taiwanese held more stigmatizing attitudes than Australian-born Chinese and Anglo-Australians. Australian-born Chinese adopted Australian cultural practices more than Chinese immigrants, but these groups did not differ in terms of adherence to Chinese cultural practices. The adoption of Australian cultural practices was significantly associated with lower stigmatizing attitudes. These findings reveal the influence of culture and acculturation processes on stigmatizing attitudes toward the mentally ill.

Keywords

stigma mental illness culture China Australia

There has been growing interest in understanding the nature and processes related to stigma and its impacts over the past few decades (Pescosolido, Martin, Lang, & Olafsdottir, 2008). Being a complex and multifaceted construct, stigma has been defined in different ways (Falk, 2001), but it is generally agreed that it is based on the negative stereotypes and judgments attached and attributed to particular characteristics or behaviors that deviate from socially constructed norms and expectations (Hayward & Bright, 1997; Phelan, Link, Stueve, & Pescosolido, 2000). Its expression is embedded in and enacted through social interaction and occurs when dominant cultural beliefs and ideals connect identified and labeled individuals to detrimental and unfavorable characteristics, which ultimately lead to discrimination (Link & Phelan, 2001).

Mental illness has been identified as a fertile area for stigma processes to operate, and negative, stigmatized attitudes toward the mentally ill have been illustrated in many studies (Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000). For example, common public perceptions of the mentally ill as dangerous and violent have been identified, alongside an unwillingness to interact with, and a desire to be socially distant from, affected people (Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999; Martin, Pescosolido, & Tuch, 2000). These stigmatizing tendencies have a detrimental impact not only on those with a mental illness but also on their family and friends (Luty, Fekadu, Umoh, & Gallagher, 2006). In particular, stigma also has the potential to significantly interfere with crucial elements necessary for recovery from mental illness, impeding the sufferer’s ability to seek help and support, to utilize mental health services, and to comply with treatment (Rusch, Angermeyer, & Corrigan, 2005; Sirey et al., 2001).

Given the detrimental impact of stigma on the mentally ill, it is important to consider the factors affecting the nature of stigma. One of these, as implied by the Framework Investigating Normative Influences on Stigma (FINIS; Pescosolido et al., 2008), is culture. Consistent with Goffman’s (1968) pioneering sociological work on stigma, the FINIS emphasizes the fundamental role of the particular rules governed by political, social, and cultural contexts that guide behavior and define it as appropriate, expected, or customary (Pescosolido et al., 2008). Understanding these cultural underpinnings of stigma may generate greater insight and awareness into why specific areas attract stigma.

Stigma and Culture

Because culture incorporates the shared attributes, meanings, values, and beliefs of a group and shapes expectations and perceptions during social interaction (Boucher & Maslach, 2009), different cultural groups may have unique understandings of social processes and what constitutes adequate and optimal functioning. Consequently, culture may shape particular conceptualizations of and influence perceptions and attitudes toward mental illness. For example, studies (e.g., Hsiao, Klimidis, Minas, & Tan, 2006; Lai, Zhuo, Singla, Wu, & Yang, 2009) have shown that Chinese populations hold particularly stigmatized attitudes toward mental illness based on core Confucian values and beliefs. According to Lai et al., Confucianism views mental illness in terms of the sufferer’s dependency on others and their inability to fulfill valued roles and duties. It is seen to result from weak character and moral lapse and is viewed as punishment for one’s transgressions (Lam et al., 2010). As a result, mental illness leads to unstable relationships and marginalization due to “loss of face” within the community, not only for the individual but also for the extended family (Lam et al., 2010). Research findings related to the experiences of stigma among Chinese immigrants to America and Australia diagnosed with mental illness are consistent with this argument. Respondents in studies by Hsiao et al. (2006) and Lai et al. (2009) reported being viewed as useless and incapable, experiencing avoidance, rejection, and disrupted interpersonal relationships based on their failure to fulfill the appropriate duties and family obligations. Feelings of guilt and shame were related to an inability to honor the family’s reputation and status, which according to Confucianism is highly valued.

As theorizing and research suggest culture impacts on stigma, understanding cultural influences may have important theoretical and applied implications for stigma reduction. Unfortunately however, there has been insufficient investigation into the differences in stigma across cultures (Griffiths et al., 2006; Hamid, Simmonds, & Bowles, 2009). Furthermore, in this age of globalization, where multiculturalism is the hallmark of many developed nations, there have been few studies that have investigated how acculturation influences stigma.

Exposure to Western culture has been proposed to affect and shape attitudes toward mental illness held by immigrants from non-Western countries (Yang, 2007), and limited cross-cultural literature illustrates this (Shea & Yeh, 2008). In one study, Shokoohi-Yekta and Retish (1991) found that Chinese immigrants living in America for longer than the average immigrant (2.86 years) showed more similar (i.e., less stigmatizing) attitudes to Americans regarding mental illness than immigrants living in America for a shorter period. This suggests that the longer Chinese people have lived in America, the more likely they are to have adopted Western values, beliefs, and social processes, and consequently to have more similar and less stigmatizing attitudes toward the mentally ill.

A similar study was conducted in Australia by Fan (1999) to investigate whether Asian immigrants differ from Anglo-Australians in terms of attitudes toward mental illness. Fan found that Asian immigrants (both long-term and short-term) were more authoritarian, socially restrictive, avoidant, and fearful of the mentally ill than Anglo-Australians. However, short-term Asian immigrants held the highest levels of stigmatizing attitudes toward mental illness.

While the above two studies demonstrate the influence culture and acculturation may have on the development of attitudes toward mental illness and the possible impact of acculturation on level of stigma, there are limitations to them. Both studies comprised a university student sample, which limits generalizability of the results. Participants had been educated within the Western system and consequently may have been more exposed to Western cultural ideals and practices than other Asian immigrants. Furthermore, both studies utilized “length of time living in the new country” as a proxy for acculturation, without measuring the level of adoption of the practices of Western (mainstream) culture by participants. A further criticism of these studies is that in essence they have all assumed a uni-directional model of acculturation. It is now generally accepted that both the original cultural heritage and the new host culture play an important role in the process of acculturation, and therefore, heritage and host orientations must be measured independently (Flannery, Reise, & Yu, 2001). This model allows for interaction effects of the original and the new culture (Berry, 2003). Despite these limitations, the findings of the above studies illustrate the possible influence of acculturation to the new county’s (mainstream) cultural practices on stigma toward mental illness among Chinese and other Asian immigrants.

As there is limited research into the area, more refined research is needed to explore the influence of acculturation on stigma. In the Australian context, this is particularly important amongst the Chinese, who are one of Australia’s largest immigrant groups (Australian Bureau of Statistics [ABS], 2008), with the 2006 census indicating that 304,775 people, or 1.5% of the population, were born in China, Hong Kong, Macau, or Taiwan (ABS, 2007a), and 3.3% of the population (675,733) had Chinese or Taiwanese ancestry, either alone or with another ancestry (ABS, 2007b). It is also of interest to consider second and subsequent generations of Chinese immigrants who, although they are born in Australia, may also be exposed to and possibly identify with Chinese (heritage) culture through the socialization processes within their families.

The aim of the current study was to investigate the differences in levels of stigmatizing attitudes toward the mentally ill between Chinese people in their home country (Taiwanese), Chinese immigrants to Australia, Australian-born Chinese, and Anglo-Australians. Additionally, it aimed to assess whether level of acculturation (rather than length of stay in the new country) plays a role in stigma. We used the Vancouver Index of Acculturation (VIA; Ryder, Alden, & Delroy, 2000) to assess acculturation within the bi-directional framework. We assessed stigmatizing attitudes with the Attitudes Toward Mental Illness Scale (ATMIS; Zeng et al., 2009), which, in line with research mentioned earlier, conceptualizes stigma toward mental illness in terms of attributions of dangerousness and incompetence to people who suffer mental illness, and the desire of social distance from them.

Specifically, it was hypothesized that:

Chinese immigrants to Australia and Taiwanese would hold more stigmatizing attitudes toward the mentally ill than Australian-born Chinese and Anglo-Australians.

Australian-born Chinese would exhibit greater adoption of Australian (mainstream) cultural practices and less adherence to Chinese (heritage) cultural practices than Chinese immigrants.

Amongst Australian-born Chinese and Chinese immigrants, higher levels of stigmatizing attitudes would be predicted by greater adherence to Chinese (heritage) cultural practices and lower adoption of Australian (mainstream) cultural practices.

Method

Participants

The sample consisted of 543 participants (196 men and 347 women) from the general population in Melbourne, Australia, and Taiwan. Of these, 209 were Anglo-Australians, 37 were Australian-born Chinese, 153 were Chinese immigrants, and 144 were Taiwanese. Participants ranged in age from 18 to 92 years (M = 38, SD = 15.94). Table 1 provides a breakdown of age and gender by group. The Chinese immigrants had been in Australia for an average of 13.51 years (range = 5 to 43 years, SD = 9.06). Most of them had come to Australia from China (59.5%) and Hong Kong (24.8%). The remainder had come from various other Asian (14%) and Western (2%) countries.

Table 1.

Gender and Mean Age of Members of Each Group

Group	Gender	n	M	SD
Anglo-Australian	Male	76	41.58	17.65
	Female	133	37.07	15.92
Australian-born Chinese	Male	12	26.89	11.56
	Female	25	31.56	16.80
Chinese immigrant	Male	55	42.30	16.24
	Female	98	39.36	17.03
Taiwanese	Male	53	33.70	10.57
	Female	91	38.75	14.41

Measures

Participants completed a questionnaire consisting of three sections. The first section included questions designed to elicit demographic information and contact/experience with mental illness. In this section participants in Australia were asked to indicate whether they saw themselves as Anglo-Australian, Australian-born Chinese, Chinese immigrant, or Other (and describe). The second section assessed stigma, and the third, only for Australian-born Chinese and Chinese immigrants, assessed acculturation.

Stigma toward mental illness was assessed with the Attitudes Toward Mental Illness Scale (ATMIS; Zeng et al., 2009). The scale includes 26 items divided into three subscales, assessing desire for social distance (14 items, e.g., “I would not want to live with someone who has a mental illness”), attributions of danger (8 items, e.g., “The mentally ill living freely in society will be dangerous for others in the community”), and perceived competence (4 items, e.g., “The mentally ill are unable to live independently”). Participants use a 5-point response format ranging from strongly disagree (0) to strongly agree (4) to respond to each item. Responses are summed and averaged to produce a mean score for each subscale, and a total score can be obtained by summing the three subscales. Higher scores suggest more stigmatizing attitudes. The ATMIS scale exhibits adequate validity and excellent internal consistency, with Cronbach’s α being .89. For the subscales, α ranges from .49 to .83 (Zeng et al., 2009).

For Chinese participants in Australia, acculturation was assessed with the Vancouver Index of Acculturation (VIA; Ryder et al., 2000). The Chinese language version was adapted from that used in a study of Chinese in the United States by Weaver and Kim (2008), and the English version used was similarly adapted from the original scale for the Australian context. The VIA included then two subscales, one for each cultural orientation: Chinese (heritage) and Australian (mainstream). Each subscale has 10 items, which are identically worded except for the culture referenced. Examples of items include “It is important for me to maintain or develop the practices of my heritage culture” and “I believe in mainstream Australian values.” Using a 9-point response format ranging from strongly disagree (1) to strongly agree (9), participants were asked to rate the extent to which they agreed or disagreed with each item. Responses were summed and averaged to produce a mean score for each subscale. Higher subscale scores denote higher levels of adherence to and adoption of the practices of the culture referenced. The VIA has adequate concurrent and factorial validity and good internal reliability. Ryder et al. reported Cronbach’s α for the Heritage dimensions of .91, .92, and .91, for samples of undergraduate students of (a) Chinese heritage, (b) non-Chinese East Asian heritage (Japanese, Korean, and Vietnamese), and (c) non-English-speaking non-Chinese and non–East Asian (e.g., East Indian, Italian, or Arabic) heritage. For the Mainstream dimension, the corresponding Cronbach’s αs were .89, .85, and .87. For the American-Chinese version of the instrument adapted for use in the current study, Weaver and Kim (2008) reported Cronbach’s α coefficients of above .80 for both the Heritage orientation scale and for the Mainstream orientation scale.

English and Chinese language versions of both instruments were offered to Chinese participants in Australia. The original version of the ATMIS was produced in Chinese by Zeng et al. (2009). This version was translated into English by a Chinese professor fluent in English and then back translated by another bilingual Chinese professor and checked for its equivalence in meaning.

Procedure

Approval to undertake this project was obtained from the University Ethics Committee. In Australia, participants were recruited from a suburban area of Melbourne that has a relatively high proportion of Chinese residents via letterbox drops, by word of mouth, and through Chinese groups/associations. Participants were given a package containing both English and Chinese versions of a plain language statement (PLS) explaining the details and information relevant to the study, the questionnaire, and a reply paid envelope. After reading the PLS, participants completed the anonymous questionnaire in their language of choice. Anglo-Australians were only required to complete the ATMIS, whereas Chinese participants (both immigrants and Australian-born) were required to complete the ATMIS and VIA. The questionnaire took 10 to 15 minutes to complete. By completing the questionnaire and sending it back, participants provided consent to participate in the study. The response rate was 44%, but due to the anonymous nature of the letterbox drop and return mailing of questionnaires, it is not possible to provide response rates for each group. The Taiwanese ATMIS data were collected by Zeng et al. (2009).

Results

The descriptive summary of the data, including Cronbach’s α coefficients for each scale, is presented in Table 2. Preliminary analyses of assumption testing were conducted to check for accuracy of data entry, missing data, normality, linearity, univariate and multivariate outliers, and multicolinearity and singularity. No serious violations were noted.

Table 2.

Means and Standard Deviations on the Stigma Dimensions by Group and Gender

	Competence		Dangerousness		Social Distance		Total Stigma		Mainstream Culture		Heritage Culture
Group	M (SD)	α	M (SD)	α	M (SD)	α	M (SD)	α	M (SD)	α	M (SD)	α
Anglo-Australian
Males (n = 76)	4.30 (2.32)	.52	9.39 (4.58)	.78	16.50 (7.27)	.81	30.20 (11.88)	.87
Females (n = 133)	3.85 (2.36)	.58	9.60 (4.23)	.74	13.44 (7.37)	.86	26.89 (12.32)	.90
Total (n = 209)	4.01 (2.35)	.56	9.53 (4.35)	.75	14.56 (7.47)	.85	28.10 (12.24)	.89
Australian-born Chinese
Males (n = 12)	5.33 (2.60)	.33	12.17 (5.86)	.89	17.83 (8.59)	.89	35.33 (37.04)	.90	73.92 (7.55)	.77	67.00 (14.22)	.91
Females (n = 25)	5.28 (2.37)	.34	13.12 (5.21)	.84	18.64 (7.73)	.84	37.04 (13.28)	.90	75.76 (8.57)	.86	67.12 (12.41)	.88
Total (n = 37)	5.30 (2.41)	.34	12.81 (5.37)	.86	18.38 (7.91)	.85	36.49 (13.32)	.82	75.16 (8.19)	.84	67.08 (12.82)	.89
Chinese immigrants
Males (n = 55)	7.75 (2.82)	.55	16.05 (5.51)	.81	26.78 (8.23)	.84	50.58 (14.08)	.89	62.95 (10.61)	.82	73.00 (12.57)	.92
Females (n = 98)	7.10 (3.32)	.60	18.19 (6.42)	.85	27.37 (10.58)	.89	52.65 (18.37)	.93	64.05 (9.95)	.84	69.80 (13.77)	.93
Total (n = 153)	7.33 (3.16)	.59	17.42 (6.17)	.84	27.16 (9.78)	.88	51.91 (16.94)	.84	63.65 (10.17)	.83	70.95 (13.40)	.92
Taiwanese
Males (n = 53)	6.30 (3.12)	.71	16.96 (5.36)	.72	26.40 (8.05)	.83	49.66 (14.73)	.90
Females (n = 91)	6.87 (3.20)	.66	18.07 (6.06)	.83	27.33 (9.17)	.87	52.26 (16.94)	.93
Total (n = 144)	6.66 (3.17)	.67	17.66 (5.82)	.80	26.99 (8.76)	.86	51.31 (16.16)	.92

A one-way ANOVA revealed that there were significant age differences across the four groups, F(3, 542) = 4.70, p < .01, η² = .25. Post hoc analyses indicated that Australian-born Chinese (M = 30.04) were younger than both Anglo-Australians (M = 38.71, p < .05) and Chinese immigrants (M = 40.42, p < .01). A chi-square analysis revealed that there were no significant differences in gender distribution across groups, χ²(3) = .255, p > .05.

In order to determine whether gender was related to stigma, separate one-way analyses of variance (ANOVA) were conducted for each group (Anglo-Australians, Australian-born Chinese, Chinese immigrants, and Taiwanese), with the stigma subscales as dependent variables. The ANOVA for Anglo-Australians was significant, F(3, 208) = 4.92, p < .001, η² = .07, with post hoc testing indicating males (M = 16.50) scored higher than females (M = 13.44) on the Social Distance subscale (see Table 2). For Chinese immigrants, the ANOVA was also significant, F(1, 152) = 4.05, p < .01, η² = .08, with post hoc testing indicating females (M = 18.19) scored significantly higher than males (M = 16.05) on the Dangerousness subscale (see Table 2). The ANOVAs for Australian-born Chinese and Taiwanese were not significant. Additional one-way ANOVAs were conducted to examine the relationships between gender and acculturation (heritage culture and mainstream culture) for Australian-born Chinese and Chinese immigrants. Neither ANOVA was significant, indicating there were no significant gender differences in relation to acculturation in either group.

Bivariate correlations found that age was significantly correlated to dangerousness, social distance, and total stigma among Australian-born Chinese (see Table 3), indicating that older participants exhibited more stigmatizing attitudes. Additionally age was significantly positively correlated to competence, social distance, and total stigma among Chinese immigrants. There were significant positive correlations between age and competence, dangerousness, social distance, and total stigma among Taiwanese. There were no significant correlations between age and stigma for Anglo-Australians.

Table 3.

Pearson’s Correlations Between Age and Stigma Within Groups

Group	Competence	Dangerousness	Social Distance	Total Stigma
Anglo-Australian	.08	−.03	.12	.08
Australian-born Chinese	.16	.37*	.38*	.408*
Chinese immigrant	.18*	.12*	.20*	.20*
Taiwanese	.36**	.24**	.25**	.29**

p < .05 (two-tailed). **p < .01 (two-tailed).

Furthermore, bivariate correlations investigated the relationship between age and acculturation for Australian-born Chinese and Chinese immigrants. There were no significant correlations between age and mainstream culture (r = –.27 and r = –.08, p > .05, respectively) or heritage culture (r = –.07 and r = .00, p > .05, respectively) in either group. The correlation between mainstream culture and heritage culture was –.03 for Australian-born Chinese and –.02 for Chinese immigrants, suggesting that the two dimensions are independent of each other.

To test the first hypothesis, that Taiwanese and Chinese immigrants would hold more stigmatizing attitudes toward the mentally ill than Australian-born Chinese and Anglo-Australians, a multivariate analysis of covariance (MANCOVA) was conducted. As the analyses reported above indicated that groups (independent variable) differed by age, and gender and age were associated with various dimensions of stigma (dependent variables) in various groups (see Tables 2 and 3), age and gender were used as covariates in this analysis.

Using Pillai’s Trace criterion, the model was significant, F(9, 1,611) = 34.33, p < .001, partial η² = .13. Univariate analyses revealed significant differences between groups for competence, F(3, 537) = 48.16, p < .001, partial η² = .21, dangerousness, F(3, 537) = 92.97, p < .001, partial η² = .34, and social distance, F(3, 537) = 91.98, p < .001, partial η² = .34. Post hoc analyses revealed no significant difference between Chinese immigrants and Taiwanese on any of the dimensions of stigma. However, significant differences on all dimensions were identified for all other combinations of groups (see Table 2). Anglo-Australians scored less than each of the other groups on dangerousness (p < .001 in each case), competence (p < .001 in each case, except vs. Australian-born Chinese, p < .01), and social distance (p < .001 in each case, except vs. Australian-born Chinese, p < .01). Australian-born Chinese scored significantly less than Chinese immigrants and Taiwanese on all three subscales (p < .01 and p < .05, respectively, for competence and p < .001 in each case for dangerousness and social distance).

In order to test the second hypothesis, that Australian-born Chinese would exhibit greater adoption of Australian (mainstream) cultural practices and less adherence to Chinese (heritage) cultural practices than Chinese immigrants, a one-way ANOVA was conducted. The ANOVA was significant, F(1, 189) = 40.89, p < .001. Post hoc analyses revealed that Australian-born Chinese scored higher on mainstream culture than Chinese immigrants (p < .001, see Table 2). There were no significant differences between Australian-born Chinese and Chinese immigrants on heritage culture.

The third hypothesis proposed that among Australian-born Chinese and Chinese immigrants, the level of stigmatizing attitudes held would be predicted by level of adherence to Chinese (heritage) cultural practices and level of adoption of Australian (mainstream) cultural practices, with the former having a positive relationship and the latter a negative relationship. To test this hypothesis, a multiple group path analysis was conducted using Mplus Version 6. The independent variables were VIA mainstream and heritage cultural adherence, and the dependent variables were the three stigma subtypes. Moderation of the relationships across the two participant groups was evaluated using the invariance testing procedure described by Ho (2006). Specifically, two models were compared: an unrestricted model where paths were free to vary across both groups, χ²(9) = 17.35, p < .05, CFI = 0.963, and a restricted model where paths were constrained to equality across both groups, χ²(3) = 10.17, CFI = 0.968. If the paths vary significantly across participant groups, the chi-square statistic will indicate a significantly better fit for the unrestricted model compared to the restricted model. Results from the invariance testing suggested that there was no significant difference between the restricted and unrestricted models and that the path coefficients were not significantly different across the two participant groups, Δχ² = 7.18(6), p > 0.05. Given this, the restricted model was retained as the final model.

In the final model, four of the six paths relating the two dimensions of acculturation to the three dimensions of stigma were significant (see Table 4). Endorsement of mainstream cultural practices was associated with lower levels of stigmatizing attitudes related to competence, dangerousness, and social distance in both groups. Endorsement of heritage cultural practices was associated with higher attributions of dangerousness to the mentally ill within both groups.

Table 4.

Associations Between Acculturation and Stigma for Australian-Born Chinese and Chinese Immigrants

Relationship	β for Australian-Born Chinese	β for Chinese Immigrants
Competence
Mainstream culture-competence	−0.14*	−0.18*
Heritage culture-competence	0.02	0.02
Dangerousness
Mainstream culture-dangerousness	−0.19*	−0.23*
Heritage culture-dangerousness	0.14*	0.14*
Social distance
Mainstream culture-social distance	−0.23*	−0.28*
Heritage culture-social distance	0.05	0.05

Note. None of the paths are significantly different across the two groups.

p < 0.05.

Discussion

The present study aimed to identify differences in levels of stigmatizing attitudes toward the mentally ill between Chinese people in their home country (Taiwan), Chinese immigrants to Australia, Australian-born Chinese, and Anglo-Australians. In addition, the study aimed to assess the degree to which level of adherence to heritage culture and the new mainstream culture plays a role in stigmatizing attitudes toward those with a mental illness.

As predicted in Hypothesis 1, Chinese immigrants and Taiwanese held significantly more stigmatizing attitudes toward the mentally ill than Australian-born Chinese and Anglo-Australians. They did not differ from each other with regard to their levels of stigmatization of the mentally ill. Compared to Australian-born Chinese and Anglo-Australians, they perceived the mentally ill to be more dangerous and less competent, and they wanted more social distance from them. These findings are consistent with and may provide an explanation for the negative experiences of avoidance, rejection, and disrupted interpersonal relationships among Chinese immigrants to America and Australia who have been diagnosed with a mental illness (Hsiao et al., 2006; Lai et al., 2009).

Significantly, Anglo-Australian participants reported less stigmatizing attitudes than all other groups, including the Australian-born Chinese. This might be explained, at least in part, by the differential value placed on collectivism and individualism in Chinese and Western cultures (Shea & Yeh, 2008). In collectivist communities, an individual’s identity is embedded in family and social relationships, and people are judged by how they behave in accordance with the group (Hsiao et al., 2006). By contrast, in individualistic Western societies, autonomy and personal rights are emphasized over conformity (Hsiao et al., 2006). As mental illness is considered a deviation from the norm, it might be expected this would impact more negatively in Chinese communities where conformity and family obligation are highly valued (Triandis, 1989).

Confucian beliefs may also play a role in the higher levels of stigma reported by Chinese immigrants and Taiwanese, and to a lesser extent Australian-born Chinese, relative to Anglo-Australians. Confucian philosophy defines mental illness in terms of dependency on others, weak character, and inability to fulfill obligations, and is therefore viewed with extreme disfavor, leading to marginalization and “loss of face” for the individual and their family within the broader community (Lam et al., 2010; Yang, 2007).

That Australian-born Chinese held significantly more stigmatizing attitudes toward the mentally ill than Anglo-Australians suggests that, regardless of place of birth, aspects of Chinese culture may be associated with more stigmatized attitudes toward mental illness, as suggested by Hsiao et al. (2006) and Lai et al. (2009). However, in light of the above finding that Australian-born Chinese had lower levels of stigma than Chinese immigrants and Taiwanese, the need to further explore the role of acculturation is evident.

Consistent with Hypothesis 2, Australian-born Chinese were found to adopt Australian cultural practices more so than Chinese immigrants. This may be explained by differences in the level of exposure to Australian culture, in that Chinese people born and brought up in Australia have had greater exposure to mainstream cultural practices than Chinese immigrants. However, contrary to predictions, there was no significant difference between Australian-born Chinese and Chinese immigrants in terms of adherence to Chinese cultural practices. In line with Berry’s (1997, 2003) bi-cultural adaptation style, these results suggest that Australian-born Chinese, while having greater exposure to and adoption of Australian cultural practices, concurrently adhere to their Chinese cultural practices. This is possible because adherence to heritage culture is independent of adoption of mainstream culture, as shown by bivariate correlations.

Given this finding, if, as suggested above, aspects of Chinese culture are associated with stigmatizing attitudes toward mental illness, the maintenance of Chinese cultural practices may explain why Australian-born Chinese, as well as the other Chinese groups, recorded higher levels of stigma than Anglo-Australians. However, the Australian-born Chinese were in turn less stigmatizing than Chinese immigrants, suggesting that there may be an interaction between their traditional cultural adherence and their greater adoption of Australian cultural values, beliefs, and social processes that leads to reduced stigma.

As predicted by Hypothesis 3, and in keeping with literature suggesting that exposure to Western cultural practices may affect and shape attitudes toward mental illness (Shea & Yeh, 2008; Yang, 2007), the adoption of Australian cultural practices by Australian-born Chinese and Chinese immigrants contributed uniquely and significantly to less stigmatizing attitudes toward the mentally ill for all three dimensions of stigma. Given that Chinese immigrants adopt mainstream Australian practices less than Australian-born Chinese, this may explain why Chinese immigrants have more stigmatizing views than Australian-born Chinese.

These results parallel those of previous research suggesting that Chinese immigrants living longer in America (Shokoohi-Yekta & Retish, 1991) and Asian immigrants living longer in Australia (Fan, 1999) hold attitudes toward mental illness that are more similar to those of Anglo-Americans and Anglo-Australians, and are less stigmatizing than those of shorter-term immigrants. The present study, using a validated measure of acculturation, confirmed the inferences arising from these previous, less rigorous studies by demonstrating that the level of adoption of the new county’s (mainstream) cultural practices was associated with less stigmatizing attitudes toward the mentally ill.

While this is perhaps a convincing argument, stigmatization of the mentally ill cannot be attributed simply to adherence to Chinese culture. Inconsistent with predictions of Hypothesis 3, the level of adherence to Chinese cultural practices among Australian-born Chinese and Chinese immigrants was associated with only one dimension of stigmatization, the attribution of dangerousness to the mentally ill. A propensity to make attributions of dangerousness may be a more general trait among Chinese people that is simply reflected here. Or, as stated above, cultural differences in notions of “normal” or optimal functioning set the standard for what kind of phenomena will be stigmatized or perhaps considered dangerous. Consistent with this proposal, Ban, Kashima, and Haslam (2012) have recently proposed that cultural variations in conceptions of the “normal” person lead to variations in conceptions of abnormality. They suggest that in East Asian cultures deviance may not be identified by irrational mental states but by violations of social obligation, as suggested in the introduction to this study where notions derived from Confucian thought were discussed. Thus, the way the self is construed, or other factors, may mediate the relationship between culture and stigma.

It is also notable in this study that preliminary analyses prior to hypothesis testing indicated that Anglo-Australian males were more likely to seek social distance from the mentally ill than Australian females. Additionally, Chinese immigrant women regarded the mentally ill as more dangerous than did men. Age was also found to be positively associated with most dimensions of stigma in each of the three Chinese groups. While this finding could be accounted for by older Chinese people feeling less secure in their environment and possibly less educated than younger people, further research is warranted to investigate how stigmatizing attitudes are shaped by gender-role socialization and age.

A strength of our study was the inclusion of four groups, with the three Chinese groups having different levels of potential contact with Australian culture. In an advance on other studies in this area, we also assessed cultural orientation of Chinese living in Australia rather than relying on proxy measures, and furthermore, we used the bi-directional framework. Our measure of stigma was developed in China and included constructs that were relevant to Chinese. However, in contrast to many cross-cultural studies, a possible limitation is that these stigma constructs may be more relevant in the Chinese than Western cultural context.

There are several limitations inherent in the current study that should be noted. The correlational nature of the analyses and cross-sectional research design precludes any temporal or causal statements, and the response rate in Australia of only 44%, which, although higher than most community surveys, raises questions about the representativeness of the sample. Furthermore, the sample of Australian-born Chinese (n = 37) was considerably smaller than the other samples, and the reliability coefficients for the competency subscale of the ATMIS were low. This may be due to the small number of items (4 items) pertaining to the competency variable, but in any case, it casts some doubts on the findings related to this dimension of stigma. Furthermore, the small sample size limits the conclusions that can be drawn regarding gender differences in groups.

Future studies could be longitudinal in nature and recruit equivalent sample sizes for each group to further examine differences. Furthermore, in this study, differences among Chinese immigrants from different countries of origin were not examined due to an insufficient spread within the immigrant group. Therefore, assumptions of cultural similarity across different countries of origin were made. As mental illness was not defined for the purposes of the study, cultural factors may reflect differences in the interpretation of questions and thus have influenced responses. Participants may have used cultural stereotypes of mental illness, or had different disorders in mind, when they responded to the stigma questionnaire. Because people have different explanations/causal beliefs for mental illness generally, and different disorders specifically (Haslam, Ban, & Kaufmann, 2006; Read, Haslam, Sayce, & Davies, 2006), this may also have affected their responses. Dangerousness, for example, has been associated with disorders such as schizophrenia more than with major depressive disorder (Jorm & Griffiths, 2008). Last, it should be noted that acculturation dimensions were only weakly associated with stigma, and therefore, future research should explore other potential influences.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

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