Social Psychology

R E S E A R C H A R T I C L E

Stigma towards psychosis: Cross-cultural
differences in prejudice, stereotypes, and
discrimination in White British and South Asians

Sehar Ahmed1 | Michèle D. Birtel1,2 | Melissa Pyle3 |

Anthony P. Morrison1,3

1Division of Psychology and Mental Health,

University of Manchester, Manchester, M13

9PL, UK

2School of Human Sciences, University of

Greenwich, London, SE10 9LS, UK

3Psychosis Research Unit, Greater

Manchester Mental Health NHS Foundation

Trust, Manchester, M25 9WS, UK

Correspondence

Michèle D. Birtel, School of Human Sciences,

University of Greenwich, London, SE10 9LS,

UK.

Email: [email protected]

Abstract

Public stigma towards people with mental health problems

has been demonstrated in Western societies. Little is known

about non-Western cultures and whether cultures differ in

their perceptions of people with mental health problems.

Aim of this study was to examine cultural differences in

prejudice, stereotypes, and discrimination towards people

with psychosis. Participants were from White British and

South Asian backgrounds (N = 128, aged 16–20 years) rec-

ruited from two schools and colleges in the United King-

dom. They completed a cross-sectional survey on affective,

cognitive, and behavioural dimensions of stigma. Results

revealed significant cultural differences on all three stigma

dimensions. South Asians attributed higher anger (prejudice)

and dangerousness (stereotypes) to people with psychosis

than White British. They also reported lower willingness to

help, greater avoidance, and higher endorsement of segre-

gation (discrimination). The effects of ethnic group on help-

ing intentions, avoidance, and segregation endorsement

were mediated by anger and by dangerousness. Under-

standing cultural differences in stigma towards psychosis

will be important for designing stigma interventions as well

as treatments for people with different cultural

backgrounds.

Received: 25 March 2019 Revised: 8 August 2019 Accepted: 9 August 2019

DOI: 10.1002/casp.2437

J Community Appl Soc Psychol. 2019;1–15. wileyonlinelibrary.com/journal/casp © 2019 John Wiley & Sons, Ltd. 1
J Community Appl Soc Psychol. 2020;30:199–213. wileyonlinelibrary.com/journal/casp © 2019 John Wiley & Sons, Ltd. 199

K E Y W O R D S

cultural differences, mental health, psychosis, South Asians,

stigma

1 | INTRODUCTION

Public stigma towards people with mental health problems is widespread in Western countries, with psychosis being

one of the most stigmatized mental health problems (Barry, McGinty, Pescosolido, & Goldman, 2014; Crisp, Gelder,

Rix, Meltzer, & Rowlands, 2000; Huggett et al., 2018; Phelan, Link, Stueve, & Pescosolido, 2000; Wood, Birtel,

Alsawy, Pyle, & Morrison, 2014). Mental health problems are universal; however, culture can influence the severity

of stigma experienced; for example, stigma can be more severe in non-Western cultures with a higher emphasis on

family and relationships such as Asian cultures (Lauber & Rössler, 2007; Ng, 1997). Additionally, migration status is

associated with psychosis (Cantor-Graae & Selten, 2005) and stigma (Major & O’Brien, 2005). With the world

becoming more and more socially diverse, ethnic minority group members living in a dominant White society face

challenges not only in terms of adapting to the host culture (Berry, 1997) but also utilize mental health services less

(Kapadia, Nazroo, & Tranmer, 2016), experience discrimination, and generally report poorer health (Major, Mendes,

& Dovidio, 2013) than ethnic majority group members.

Whereas there is a wealth of research on the negative consequences of stigma on people’s quality of life (Cor-

rigan, Markowitz, Watson, Rowan, & Kubiak, 2003; Major et al., 2013; Major & O’Brien, 2005), little is known about

cultural differences in the type of stigma towards psychosis. Previous research has mainly focused on examining

mental health stigma in Western cultures; however, these findings cannot be generalized to individuals from non-

Western cultures living in a Western culture, such as South Asians living in the United Kingdom. The present study

aimed at addressing this empirical gap in cross-cultural differences, by comparing White British and South Asian

young people living in the United Kingdom in their prejudice, stereotypes, and discrimination towards people with

psychosis.

2 | PSYCHOSIS

Psychosis (also labelled “psychotic experiences” or “psychotic episode”) is a mental health problem with symptoms of

auditory hallucinations, delusional beliefs, and disorganized thinking and speech. These experiences can severely dis-

tress individuals and change their behaviour (National Health Service [NHS] Choices, 2018). The Adult Psychiatric

Morbidity Survey in England in 2014 (McManus, Bebbington, Jenkins, & Brugha, 2016) estimated the lifetime preva-

lence of a psychotic disorder at 0.7%. In our study, we focused on young people (16–20 years old) and ethnic minori-

ties (South Asians) as they are particularly vulnerable. First, it is often during adolescence when the first episode of

psychosis occurs (NHS, 2016; Kessler et al., 2007). Among the 16- to 24-year-olds, the prevalence is estimated at

0.4%, then increasing among the 25- to 34-year-olds (0.5%) and 35- to 44-year-olds (1%; McManus et al., 2016).

Not only treatment is most effective when accessed at early stages, but also stigma interventions that are incorpo-

rated in schools’ curriculum (such as increasing knowledge or intergroup contact; Rüsch, Angermeyer, & Corrigan,

2005) can challenge prejudice and discrimination from an early age on. Second, ethnic minorities are at greater risk

for mental health problems such as psychosis (Major et al., 2013). In the United Kingdom, South Asians are the larg-

est ethnic minority group with over three million people (Office for National Statistics, 2011). South Asians have a

greater risk for psychotic disorders in England (0.9% prevalence) compared with Whites (0.5%). In particular, cities in

the North West of England where our data collection took place have one of the highest numbers of people with

2 AHMED ET AL.200 AHMED ET AL.

psychosis (McManus et al., 2016; Public Health England, 2016). In addition to the severe consequences of psychosis

for people’s quality of life, it is also one of the most stigmatized mental health problems (Crisp et al., 2000; Wood

et al., 2014).

3 | STIGMA TOWARDS PSYCHOSIS

On the basis of the multicomponent model of attitudes (Zanna & Rempel, 1988), public stigma has been conceptual-

ized as having three components, it is the combination of negative affect (feelings such as anger), derogatory cogni-

tive beliefs (stereotypes and inaccurate knowledge), and hostile behaviour (discrimination; Brown, 2011; Corrigan &

Watson, 2002; Thornicroft, Rose, Kassam, & Sartorius, 2007). Belonging to a stigmatized group can result in a deval-

uation of one’s social identity (Crocker, Major, & Steele, 1998; Steele, Spencer, & Aronson, 2002) and social identity

threat (Major & O’Brien, 2005) as well as internalized stigma and label avoidance (Corrigan & Watson, 2002; Link,

Struening, Neese-Todd, Asmussen, & Phelan, 2001). Processes of negative affect, stereotypes, discrimination, and

social identity threat can have a wider impact on health and general quality of life of people with mental health prob-

lems (Corrigan & Watson, 2002; Link et al., 2001; Link, Struening, Rahav, Phelan, & Nuttbrock, 1997; Perlick et al.,

2001; Rosenfield, 1997; for a review, see Major et al., 2013).

People with psychosis experience severe public stigma in terms of negative affective reactions, false stereotypi-

cal beliefs, and discriminatory behaviour (Barry et al., 2014; Corrigan et al., 2003; Crisp et al., 2000; Phelan et al.,

2000; Wood et al., 2014). In fact, psychosis is associated with the most negative stereotypes than other mental

health problems such as depression or anxiety disorder. For example, people with psychosis are seen as a danger to

others and as unpredictable (Angermeyer, Breier, Dietrich, Kenzine, & Matschinger, 2005; Crisp et al., 2000; Wood

et al., 2014).

Corrigan and colleagues’ attribution model of public stigma towards people with mental health problems (Cor-

rigan, 2000; Corrigan, 2012; Corrigan et al., 2003), in line with the multicomponent model of attitudes, distinguishes

between affective prejudice (anger, pity, and fear), stereotypes (blame and beliefs about dangerousness) and discrimi-

nation (unwillingness to help, social avoidance, recommendations for mandatory treatment, and the segregation of

people with mental health problems from the community). Attributions about the cause and controllability of mental

health problems such as beliefs that people are responsible for and have control over their condition (blame) as well

as perceptions that they are dangerous can lead to negative affective reactions of anger, fear, and pity, which in turn

can lead to discriminatory behaviour such as withholding help and rejection (avoidance, recommendations for segre-

gation, and coercion; Corrigan et al., 2003).

Research on mental health problems including psychosis has largely focused on Western cultures, whereas less is

known about how the type of stigma differs in non-Western cultures, in particular in those with migration status in a

majority host society. Importantly, cultural differences in perceptions of mental health problems have implications

for designing interventions to reduce stigma. If there are cultural differences in the endorsement of stereotypes,

which can lead to discriminatory behaviour, then interventions may need to be tailored to specific cultures in order

to be effective.

4 | CULTURE AND MENTAL HEALTH STIGMA

Previous research suggests that mental health cannot be understood in isolation from its sociocultural context and

that Western concepts cannot be directly applied to non-Western cultures but that culture influences stigma

towards mental health (for a review, see Abdullah & Brown, 2011; Lauber & Rössler, 2007). Mental health problems

and the stigma associated with them exist universally. However, explanations for mental disorders and the severity

of stigma varies between cultures. For example, in Asian cultures the distinction between physical and mental health

problems, between the body and the mind, does not exist as it does in Western cultures. This means that in Asian

AHMED ET AL. 3AHMED ET AL. 201

cultures, mental health is somaticized and medicalized, that is, there is a tendency to experience psychological symp-

toms as somatic symptoms and to focus on medical instead of psychological help. Additionally, explanations for men-

tal health problems are reported to be different (Lauber & Rössler, 2007; Mirza, Birtel, Pyle, & Morrison, 2019).

Whereas Western cultures rather seem to emphasize biological or psychosocial approaches to treatment, in Asian

countries, larger emphasis is placed on religious, supernatural, and magical approaches. Furthermore, Mirza et al.

(2019) found that South Asian adolescents living in the United Kingdom tend to report greater supernatural causes

as explanations for mental health problems such as psychosis, in particular, when they experience low to moderate

psychotic experiences. As a consequence, when healthcare is sought, it focuses on somatic symptoms (Lauber &

Rössler, 2007). In the United Kingdom, statistics show that South Asians are less likely to engage with mental health

services and less likely to complete treatment than Whites (Baker, 2018). Research has suggested several reasons for

the barriers to mental health help seeking in ethnic minorities. First, causal explanations of mental health can impact

help seeking. South Asians have a greater tendency to attribute psychosis to supernatural causes and seek help from

faith institutions first, which can delay help seeking from services providing medication and therapy (Burns,

Jhazbhay, & Emsley, 2011; Islam, Rabiee, & Singh, 2015). Second, stigma from the public generally prevents people

from disclosing or seeking help for their mental health problem (Schulze & Angermeyer, 2003). Such stigma can be

greater in non-Western cultures, which tend to place greater importance on family and relationships than Western

cultures. Therefore, stigma can affect the relations of an individual to a greater extent (Lauber & Rössler, 2007).

Although the majority of the literature examined mental health stigma in the Western world (e.g., Barry et al.,

2014; Crisp et al., 2000), stigmatizing attitudes and discriminatory behaviour towards people with mental health

problems is not limited to Western countries. There is evidence that stigma can be found across a range of different

cultures and countries, including South Asian populations originating from Pakistan, India, and Sri Lanka (Lauber &

Rössler, 2007). Lauber and Rössler’s (2007) review suggested that the tendency to view people with mental health

problems in a negative light is shared with Western societies. However, stigma from close others such as family

members is reported to be larger and to have more devastating social consequences in terms of social distance,

devaluation, and marriage in Asian cultures. Pawar, Peters, and Rathod (2014) conducted a study in India in which

90% of patients had experienced mental health stigma and 86% had perceived discrimination from their colleagues,

friends, and superiors. Tabassum, Macaskill, and Ahmad (2000) also reported that some of the most commonly

endorsed attitudes by South Asians about mental health revolved around social avoidance and not having close rela-

tionships and contact with those with mental health difficulties. Research also suggests that messages about the dan-

gers of people with mental health difficulties are being conveyed to children by their parents, resulting in them

distancing themselves further (Salve, Goswami, Sagar, Nongkynrih, & Sreenivas, 2013). Additionally, stigma from

health professionals is also shared between both Western and non-Western cultures, for example, in Western coun-

tries such as the Unites States, the United Kingdom, and Australia (Nordt, Rössler, & Lauber, 2006; Van Boekel,

Brouwers, Van Weeghel, & Garretsen, 2013), Pakistan (Naeem et al., 2006), and Sri Lanka (Fernando, Deane, &

McLeod, 2010).

There is currently little insight into cross-cultural differences in the type of stigma towards psychosis, in particu-

lar, considering ethnic minorities living in a dominant Western culture. The United Kingdom’s largest ethnic minority

group, South Asians, have to cope with different issues than those living in their home countries. For example, they

can experience discrimination and poor well-being due to their stigmatized minority group status (Major et al., 2013;

Major & O’Brien, 2005), and visible ethnic differences in migrants can increase the risk for psychosis (for a meta-anal-

ysis, see Cantor-Graae & Selten, 2005). South Asians abroad also have to deal with acculturation processes, that is,

negotiating conflicts between their original cultural identity and the new identity and social norms of their host cul-

ture. These processes can result in acculturative stress and, depending on the outcome of this conflict between origi-

nal and new identity, to a reduced well-being (Berry, 1997). Additionally, experiencing psychosis would mean that

South Asians living in the United Kingdom would not only belong to a minority group based on ethnicity but also to

an additional minority group based on mental health.

4 AHMED ET AL.202 AHMED ET AL.

5 | THE PRESENT RESEARCH

Psychosis typically emerges during the developmental period of adolescence (Garralda & Raynaud, 2012; Vos &

Begg, 2003). Understanding cultural differences in the perception and stigmatization of psychosis is important

in order to design effective interventions to reduce negative attitudes and discrimination towards people with

psychosis from an early age on. The present study was conducted in a large ethnically diverse city in Northern

England. The city has an overall population of 2.7 million, with the largest ethnic groups being White British

(79.8%) and Asian British (10.2%; composed of 4.8% Pakistani; 2% Indian; and 1.3% Bangladeshi; Office for

National Statistics, 2011).

Although there is evidence for stigma towards mental health problems in both Western and non-Western cul-

tures, little research has been carried out examining the type of stigma towards psychosis, in particular, in non-

Western cultures living in a dominant White culture. We compared White British and South Asian British young

people living in the United Kingdom in their type of stigma towards people with psychosis, distinguishing between

negative affective reactions (prejudice) and negative cognitive biases (stereotypes) as well as discriminatory behav-

iour. Whereas Mirza et al. (2019) found that South Asians living in the United Kingdom tend to report lower inten-

tions to have contact with people with psychosis, an indication of stigma, we focused on disentangling the

different dimensions of stigma associated with negative affect, cognition, and behaviour, using Corrigan et al.’s

(2003, 2012) attribution model of stigma. We predicted that affective prejudice (anger, pity, and fear) and stereo-

types (perceived blame and dangerousness) towards people with psychosis would be associated with discrimina-

tory behaviour (withholding help and rejection responses). Furthermore, evidence suggests that stigma towards

people with mental health problems may be greater in Asian cultures (Lauber & Rössler, 2007). We tested the fol-

lowing hypotheses:

• H1 South Asians will report greater affective prejudice (anger, fear, and pity) towards people with psychosis

than White British.

• H2 South Asians will report more negative stereotypes (blame and dangerousness) towards people with psy-

chosis than White British.

• H3 South Asians will report more discriminatory behaviour (withholding help, avoidance, endorsement of segre-

gation, and coercion) towards people with psychosis than White British.

• H4 The relationship between ethnic group and discriminatory behaviour will be mediated by affective prejudice

and by stereotypes.

Additionally, intergroup contact theory (Allport, 1954) suggests that contact with stigmatized groups, such as

people with psychosis, is associated with lower stigma towards those groups (Pettigrew & Tropp, 2006; Reinke, Cor-

rigan, Leonhard, Lundin, & Kubiak, 2004). For example, contact with people with schizophrenia is associated with less

social avoidance, due to more positive attitudes (West, Hewstone, & Lolliot, 2014). Due to the stigma of mental

health in the South Asian community, those with mental health problems may isolate themselves from others

(Rathod, Kingdon, Phiri, & Gobbi, 2010) and therefore have less contact with people with psychosis. For this reason,

intergroup contact was included as a covariate to control and adjust for these participant characteristics. We mea-

sured contact towards people with mental health problems more generally, instead of contact specifically towards

people with psychosis, as intergroup contact research suggests that contact not only reduces prejudice towards the

AHMED ET AL. 5AHMED ET AL. 203

group one has interacted with but also towards other stigmatized groups (for an overview, see Vezzali & Stathi,

2017). Identification with being British was used as a proxy measure to test whether our South Asian sample had

adapted to the British culture or, in other words, whether the cultural identity of South Asians living in the United

Kingdom was significantly different from a British identity.

6 | METHOD

6.1 | Participants

One hundred seventy-three young people took part in the study: 109 White British and 64 South Asians. In line

with the definition by the Office for National Statistics, South Asian refers to those individuals originating from

the South Asian subcontinent, including those from India, Pakistan, Bangladesh, and Sri Lanka, but who live in the

United Kingdom. The ethnic identity of participants was determined by them self-reporting their ethnicity.1 The

exclusion criteria were as follows: not speaking or understanding English due to all measures being in English.

Thirty-two completions of the 205 participants had to be excluded from the analysis as they did not meet our

inclusion criteria of identifying themselves as either White British or South Asian. The analysis plan for this pro-

ject included an a priori decision on comparing equal sample sizes. This decision was based on recommendations

on power in unequal cell sample sizes (StataCorp, 2013). This planned strategy was then followed once data were

collected. Due to the inequality of cell sample sizes, an equivalent sample size for both groups was used via ran-

dom subsampling in SPSS, and 64 cases were randomly selected from the 109 White British group, resulting in a

final sample size of 128 participants (64 White British and 64 South Asians) included in the analysis (64 women

and 64 men). In order to detect a medium effect for both α and β paths using the bias-corrected bootstrap test

of mediation with a power of .8, the required sample size is N = 71 (Fritz & MacKinnon, 2007). Those included in

the analysis were between the age of 16 and 20 years (MWhite = 16.95, SDWhite = 0.88, MAsian = 16.53, SDAsian =

0.80; for more demographics see Table 1).

6.2 | Procedure

Head teachers of one secondary school and one college in a city in Northern England were contacted via email

and telephone. Then, they were given a copy of the participant information sheet and consent forms for the par-

ticipants and for the parents of participants younger than 18 years. These were collected from the head teachers

a week later by the researcher, and participants were given an envelope containing a set of questionnaires

through the head teacher. Upon completion, participants were asked to put the questionnaires in the envelopes,

seal them, and return to the head teacher who passed them on to the researcher. Ethical approval was received

by the local institutional research and ethics committee (Ref: 15173). As young people may not be familiar with

the term psychosis and as its cultural meanings may vary, a brief definition of psychosis from the NHS were given

to participants.

6.3 | Measures1

6.3.1 | Prior contact with people with mental health problems

Prior contact was measured by asking participants to indicate whether they had any previous contact with a person

with a mental health problem (0 = no, 1 = yes).

6 AHMED ET AL.204 AHMED ET AL.

6.3.2 | Identification with being British

The five items of the Group Identification Scale (Hornsey & Hogg, 2000) were used on a 7-point Likert scale ranging

from 1 = strongly disagree to 7 = strongly agree, for example, “I feel British.” A composite score was created by the

mean of these items (Cronbach’s αWhite = .90; Cronbach’s αAsian = .90).

Stigma towards psychosis was measured adapting the Attribution Questionnaire (Corrigan et al., 2003). All three

dimensions towards people with psychosis were measured: prejudice (anger, pity, and fear), stereotypes (blame and

dangerousness), and discrimination (helping, avoidance, segregation, and coercion). Participants were presented with

a vignette about a person named Harry who was described as having psychosis and were asked to rate statements

about Harry on a 9-point Likert scale ranging from 1 = not at all to 9 = very much. A composite score was created by

the mean of the items for each subscale, with most subscales having three items apart from anger and pity (two

items). Cronbach’s alpha was calculated for the three-item scales (criterion: α ≥ .60) and a correlation coefficient for

the two-item scales (criterion: r ≥ .50): anger, for example, “I would feel aggravated by Harry” (rWhite = .58; rAsian =

.59); fear, for example, “How scared of Harry would you feel?” (αWhite = .89; αAsian = .85); pity, for example, “How

much sympathy would you feel for Harry?” (rWhite = .58; rAsian = .62); dangerousness, for example, “I would feel

unsafe around Harry” (αWhite = .85; αAsian = .84); blame, for example, “I would think that it was Harry’s own fault that

he is in the present condition” (αWhite = .45; αAsian = .53); helping, for example, “I would be willing to talk to Harry

about his problems” (αWhite = .74; αAsian = .88); segregation, for example, “I think Harry poses a risk to his neighbours

unless he is hospitalised” (αWhite = .79; αAsian = .70); avoidance, for example, “If I were an employer, I would interview

Harry for a job” (αWhite = .67; αAsian = .60, reverse coded); and coercion, for example, “How much do you agree that

Harry should be forced into treatment with his doctor even if he does not want to” (αWhite = .59; αAsian = .43). The

TABLE 1 Participant demographics (frequencies)

Demographics White British South Asian

Gender M:F 14:50 50:14

Ethnicity

White British 64

Asian Pakistani 39

Asian Indian 19

Asian Bangladeshi 5

Asian Sri Lankan 1

Religion

No religion 33 18

Christian 28 2

Muslim 0 33

Sikh 0 2

Hindu 1 6

Other 1 1

First Language

English 64 49

Urdu 9

Punjabi 3

Arabic 1

Malayam 1

AHMED ET AL. 7AHMED ET AL. 205

scales for blame and coercion lacked internal consistency, and thus, no further analyses were conducted considering

these constructs.

7 | RESULTS

7.1 | Preliminary analyses

White British (n = 45) reported significantly more previous contact with a person with a mental health problem than

South Asians (n = 25), χ2 (1) = 13.44, p < .001. White British reported stronger identification with being British (M =

5.35, SD = 1.53) than South Asians (M = 4.64, SD = 1.51), t(126) = 2.64, p = .009, indicating that South Asians per-

ceived themselves as culturally different from White British people.

7.2 | Stigma dimensions

Descriptive statistics for all dependent measures are reported in Table 2. In order to test whether White British and

South Asians differed in stigma towards psychosis (while controlling for contact), one-way analyses of covariance

were carried out with the six stigma subscales. Ethnicity was coded as White British = 0 and South Asians = 1. Prior

contact with people with mental health problems was entered as a covariate. Results demonstrated a significant

effect on all three dimensions. South Asians reported higher levels of anger, F(1, 124) = 7.60, p = .007, partial η2 =

.06 (H1), dangerousness, F(1, 124) = 4.95, p = .028, partial η2 = .04 (H2), segregation, F(1, 124) = 4.19, p = .043, partial

η2 = .03 (H3), and avoidance, F(1, 124) = 6.76, p = .010, η2 = .05 (H3) as well as lower helping intentions, F(1, 124) =

8.24, p = .005, partial η2 = .06 (H3) than White British. The covariate was significant only for helping intentions, F(1,

124) = 6.36, p = .013, partial η2 = .05. There were no significant differences between White British and South Asians

for fear and pity, ps > .05.2, 4

7.3 | Mediation models

7.3.1 | Anger

We computed mediation analyses to assess whether the effects of ethnicity on discriminatory behaviour (reduced

helping intentions, avoidance, and endorsement of segregation) were mediated by variation in perceived anger.

Ethnicity was coded as White British = 0 and South Asians = 1. Bootstrapping analyses (1,000 subsamples, 95%

bias corrected, and accelerated confidence interval) were conducted using the PROCESS macro provided by

Hayes (2016, Model 4). Contact was entered as a covariate. Results can be found in Table 3. As hypothesized,

ethnicity significantly predicted helping, avoidance, and segregation, p < .05 for all total effects. Being of South

Asian ethnic background was associated with lower helping intentions, and greater avoidance and segregation

TABLE 2 Means (and standard deviations) for the stigma dimensions

Stigma dimension White British South Asian

Anger 2.41 (1.52) 3.16 (1.54)

Fear 2.70 (1.61) 3.14 (1.59)

Pity 7.22 (1.63) 6.88 (1.57)

Dangerousness 3.12 (1.67) 3.67 (1.57)

Helping 7.43 (1.41) 6.26 (1.97)

Segregation 2.51 (1.50) 2.98 (1.42)

Avoidance 4.00 (1.79) 4.93 (1.70)

8 AHMED ET AL.206 AHMED ET AL.

recommendation. There were significant indirect effects of ethnicity on helping, avoidance, and segregation,

through anger. As hypothesized (H4), the relationships between ethnicity (predictor) and helping, avoidance, and

segregation (outcome variables) were mediated by anger. Being of South Asian ethnic background was associated

with higher attributed anger and, in return, with lower helping intentions, greater avoidance, and higher segrega-

tion recommendation.

7.3.2 | Dangerousness

We then computed similar mediation analyses to assess whether the effect of ethnicity on discriminatory behaviour

(reduced helping, avoidance, and segregation) was mediated by variation in perceived dangerousness. Contact was

entered as a covariate. Results can be found in Table 4. As hypothesized, ethnicity significantly predicted helping,

avoidance, and segregation, p < .05 for all total effects. Being of South Asian ethnic background was associated with

lower helping intentions, and greater avoidance and segregation recommendation. There were significant indirect

effects of ethnicity on helping, avoidance, and segregation, through dangerousness. As hypothesized (H4), the rela-

tionships between ethnicity (predictor) and helping, avoidance, and segregation (outcome variables) were mediated

by dangerousness. Being of South Asian ethnic background was associated with higher attributed dangerousness

and, in return, with lower helping intentions, greater avoidance, and higher segregation recommendation.3, 4

8 | DISCUSSION

Previous research has focused on examining mental health stigma in Western cultures, little research has compared

Western with non-Western cultures living in a dominant White culture in their type of stigma. The current study

compared White British and South Asian young people in the United Kingdom in their affective prejudice, stereo-

types, and discriminatory behaviour towards people with psychosis.

First, following Corrigan et al.’s (2003, 2012) attribution model of stigma, we found support for our hypotheses

that South Asians endorse greater affective prejudice and more negative stereotypes towards people with psychosis

TABLE 3 Total, direct, and indirect effects of ethnic group on discriminatory behaviour, mediator: anger

95% BCa CI

Dependent variable B SE (B) p LL UL

Helping

Total effect −0.91 0.32 .005 — —

Direct effect −0.57 0.30 .062 — —

Indirect effect −0.34 0.15 — −0.66 −0.08

Segregation

Total effect 0.56 0.27 .043 — —

Direct effect 0.16 0.24 .516 — —

Indirect effect 0.41 0.16 — 0.09 0.74

Avoidance

Total effect 0.82 0.32 .011 — —

Direct effect 0.49 0.30 .110 — —

Indirect effect 0.34 0.15 — 0.07 0.67

Note. Contact was entered as a covariate. B, unstandardized coefficient; SE, standard error; p, reported two tailed; 95% BCa

CI, 95% bias-corrected confidence interval; LL, lower limit; UL, upper limit.

AHMED ET AL. 9AHMED ET AL. 207

than White British. Specifically, they attributed higher anger and dangerousness to people with psychosis for their

condition. Second, we found support for our hypothesis that South Asians report greater willingness to engage in

discriminatory behaviour towards people with psychosis than White British. Specifically, they reported greater inten-

tions to withhold help, avoidance, and endorsement of segregation between people with psychosis and the commu-

nity. We also found support for our hypothesis that these cultural differences in self-reported discriminatory

behaviour are mediated by prejudice (anger) and stereotypes (dangerousness).

Our findings are in line with evidence on cultural differences, which suggest that stigma towards people with

mental health problems can be greater in Asian cultures (Lauber & Rössler, 2007). Although evidence indicates

that social distance is one of the most common endorsed consequences of having a mental health problem among

South Asians (Tabassum et al., 2000), our findings indicate that this also specifically applies to psychosis and

extends to other consequences such as withholding help, avoidance, and recommending segregation between

people with psychosis and the community. Intergroup contact theory (Allport, 1954) suggests that White British

may also be less stigmatizing towards people with psychosis due to greater prior contact with people with mental

health problems (Pettigrew & Tropp, 2006). Furthermore, due to the stigma of mental health in the South Asian

community, contact with people with mental health problems may be reduced because of self-isolation of those

with mental health problems (Rathod et al., 2010). Future research should examine the role of prior intergroup

contact in cross-cultural studies on mental health stigma further, using more refined measures of contact quantity

and quality.

Although we found support for cultural differences in the endorsement of prejudice, stereotypes, and discrimina-

tory behaviour, we did not find support for cultural differences on all measures of affective prejudice (fear and pity).

One reason may be that stereotypes and discriminatory behaviour are associated with cultural norms and expecta-

tions; for example, South Asians may not be able to help or socially engage with people with psychosis due to the

stigma and consequences attached to it. However, they may still experience similar emotions as White British; for

example, they may not differ in their (internally experienced) fear or pity for people with psychosis. There may also

be a complex relationship between cultural origin and migrant status in South Asians. Future research will need to

investigate whether stigma is generally more severe in non-Western compared with Western cultures or whether

TABLE 4 Total, direct, and indirect effects of ethnic group on discriminatory behaviour, mediator: dangerousness

95% BCa CI

Dependent variable B SE (B) p LL UL

Helping

Total effect −0.91 0.32 .005 — —

Direct effect −0.71 0.31 .024 — —

Indirect effect −0.20 0.11 — −0.45 −0.02

Segregation

Total effect 0.56 0.27 .043 — —

Direct effect 0.21 0.23 .355 — —

Indirect effect 0.35 0.15 — 0.06 0.63

Avoidance

Total effect 0.82 0.32 .011 — —

Direct effect 0.49 0.28 .090 — —

Indirect effect 0.34 0.16 — 0.07 0.66

Note. Contact was entered as a covariate. B, unstandardized coefficient; SE, standard error; p, reported two tailed; 95% BCa

CI, 95% bias-corrected confidence interval; LL, lower limit; UL, upper limit.

10 AHMED ET AL.208 AHMED ET AL.

only specific aspects of stigma (cognitive and behavioural components) are more severe by using more refined mea-

sures of affective prejudice such as intergroup anxiety or empathy.

In addition to explanations focusing on how culture can affect stigma, another explanation for our findings could

be that because South Asians living in the United Kingdom are an ethnic minority group in a majority host society,

they may tend to avoid further associations with other minority groups, such as people with mental health problems.

Another reason may be limitations in our design. The vignette was based on a person named Harry, which indicated

that the person with psychosis is from a White British ethnic background, so an outgroup member for South Asians

and an ingroup member for White British. A fruitful avenue for future research may be to vary the main character of

the vignette, using a White British and a South Asian name or removing the name from the vignette to test whether

naming the target of the stigmatized group influences affective reactions. In general, using scales developed for

research in Western countries may not be easily applicable to cross-cultural studies. They may lead to lower reliabil-

ity (as some scales in our study) as well as an inability to capture potential cultural differences. An important avenue

for future research is to develop scales that make it possible to capture the culture-specific experiences of mental

health and that are developed with researchers and service users from non-Western cultures.

Due to the challenge of obtaining the same number of South Asian participants as White British participants, the

cell sample sizes were unequal and the overall sample size lower than planned. This is a limitation of the current

study, in terms of power and the type of analyses that are possible (such as more complex models). Future studies

should consider strategies reaching out to minority participants in order to obtain larger sample sizes to test more

complex models. Another limitation of the current study is that we did not collect more information about the South

Asian sample. Although we had included a measure of identification with being British as a proxy measure of adap-

tion, future research should consider important variables such as British citizenship or length of stay in the United

Kingdom.

8.1 | Implications

Stigma greatly impacts the health of people with mental health conditions further. It is associated with poorer well-

being such as lower self-esteem, depression, and poor sleep (Birtel, Wood, & Kempa, 2017; Corrigan & Watson,

2002; Link et al., 2001). Additionally, stigma has implications for the diagnosis, treatment, and management of psy-

chosis. Help seeking is frequently delayed due to fear of social exclusion from close others and society (Schulze &

Angermeyer, 2003; Wright, Gronfein, & Owens, 2000). Stigma is a major barrier to help seeking (Schomerus &

Angermeyer, 2008). Subsequently, this impedes timely diagnosis and treatment, hinders recovery and rehabilitation,

and ultimately compromises the quality of life of those with mental health difficulties. Mental health services are

reported to be underutilized by ethnic minorities, particularly South Asians (Kapadia et al., 2016). However, cross-

cultural differences exist when it comes to mental health causal beliefs, which can influence the willingness to seek

help. Spiritual and supernatural explanations are commonly held by South Asians regarding the causes of psychosis,

including the will of God, karmic retribution, and evil eye (Kulhara, Avasthi, & Sharma, 2000; Mirza et al., 2019).

South Asians are more likely to seek help from informal services, including religious leaders, prayer, and God as first

ports of call (Conrad & Pacquiao, 2005). This help seeking pattern has also been extended to South Asians living in

the United Kingdom, where there is also a reluctance to visit health practitioners for mental health problems (Fenton

& Sadiq-Sangster, 1996). Appropriate and timely help seeking from formal mental health services such as early inter-

vention services can mean better outcomes, including symptom reduction and fewer relapses (McGorry, Killackey, &

Yung, 2008).

Therefore, there is a need to understand cultural differences in stigma towards people with psychosis in order to

tackle the negative consequences of stigma on help seeking and well-being and to make service accessible and effec-

tive for those from ethnic minority backgrounds, in particular adolescents.

AHMED ET AL. 11AHMED ET AL. 209

9 | CONCLUSION

The present study contributes to understanding the processes of prejudice, stereotypes, and discrimination towards

people with psychosis in its sociocultural context. Developing a deeper understanding of cross-cultural differences in

psychosis specifically and of mental health in general may provide valuable insights for practitioners. Increased sensi-

tivity to associations between culture and mental health will enable educators and policymakers to tailor stigma

interventions and clinicians to develop treatment approaches to South Asian communities.

ENDNOTES

1 This study, a student project, was part of a larger research project that involved two students with different research
questions and different dependent measures. Therefore, other measures were administered, which were not part of the
present investigation (see Mirza et al., 2019).

2 When including the full sample, analyses yielded similar results: In the analyses of covariance, South Asians (vs. White Brit-
ish) reported significantly higher levels of anger, F(1, 168) = 8.89, p = . 003, η2 = .05 (H1), and avoidance, F(1, 168) = 7.61,
p = .006, η2 = .04 (H3), and significantly lower helping intentions, F(1, 168) = 13.70, p < .001, η2 = .08 (H3); danger, F(1,
168) = 2.84, p = .094, η2 = .02 (H2) and segregation, F(1, 168) = 2.43, p = .121, η2 = .01 (H3), showed a trend to be higher
for South Asians. In the mediation analyses, there were significant indirect effects between ethnicity and helping inten-
tions (b = −.31, SE = 0.13, 95% CI [−0.60, −0.09]), avoidance (b = .31, SE = 0.12, 95% CI [0.08, 0.57]), and segregation (b =
.37, SE = 0.14, 95% CI [0.10, 0.67]) via anger.

3 Entering both mediators (anger and dangerousness) simultaneously in the same mediation models yielded similar results.

Specifically, for segregation both anger (b = .22, SE = 0.12, 95% CI [0.01, 0.50]) and dangerousness (b = .23, SE = 0.12,
95% CI [0.03, 0.52]) were significant mediators, for helping intentions anger (b = −.32, SE = 0.15, 95% CI [−0.66, −0.05])
but not dangerousness (b = −.03, SE = 0.08, 95% CI [−0.24, 0.11]) was a significant mediator, and for avoidance danger-
ousness (b = .28, SE = 0.15, 95% CI [0.03, 0.62]) but not anger (b = .11, SE = 0.10, 95% CI [−0.05, 0.33]) was a significant
mediator.

4 When intergroup contact was excluded as a covariate, the ANCOVAs yielded similar results: South Asians reported signifi-
cantly higher levels of anger, F(1, 126) = 7.73, p = .006, partial η2 = .06 (H1), and avoidance, F(1, 126) = 9.14, p = .003, η2
= .07 (H3), marginally significantly higher levels of dangerousness, F(1, 126) = 3.72, p = .056, partial η2 = .03 (H2), and seg-
regation, F(1, 126) = 3.45, p = .066, partial η2 = .03 (H3), as well as significantly lower helping intentions, F(1, 126) =
14.93, p < .001, η2 = .11 (H3), than White British. In the mediation analyses, anger (but not dangerousness) mediated the
effects of ethnicity on discriminatory behaviour, that is, helping intentions (b = −.32, SE = 0.14, 95% CI [−0.62, −0.08]),
segregation (b = .39, SE = 0.15, 95% CI [0.12, 0.70]), and avoidance (b = .35, SE = 0.14, 95% CI [0.10, 0.64]).

ORCID

Michèle D. Birtel https://orcid.org/0000-0002-2383-9197

REFERENCES

Abdullah, T., & Brown, T. L. (2011). Mental illness stigma and ethnocultural beliefs, values, and norms: An integrative review.

Clinical Psychology Review, 31, 934–948. https://doi.org/10.1016/j.cpr.2011.05.003
Allport, G. W. (1954). The nature of prejudice. New York, NY: Addison-Wesley.
Angermeyer, M. C., Breier, P., Dietrich, S., Kenzine, D., & Matschinger, H. (2005). Public attitudes toward psychiatric treat-

ment. Social Psychiatry and Psychiatric Epidemiology, 40, 855–864. https://doi.org/10.1007/s00127-005-0958-x
Baker, C. (2018). Mental health statistics for England: Prevalence, services and funding. House of Commons Library. Retrieved

from: https://researchbriefings.parliament.uk/ResearchBriefing/Summary/SN06988
Barry, C. L., McGinty, E. E., Pescosolido, B. A., & Goldman, H. H. (2014). Stigma, discrimination, treatment effectiveness, and

policy: Public views about drug addiction and mental illness. Psychiatric Services, 65, 1269–1272. https://doi.org/10.

1176/appi.ps.201400140
Berry, J. W. (1997). Immigration, acculturation, and adaptation. Journal of Applied Psychology, 46, 5–34. https://doi.org/10.

1111/j.1464-0597.1997.tb01087.x

12 AHMED ET AL.210 AHMED ET AL.

Birtel, M. D., Wood, L., & Kempa, N. J. (2017). Stigma and social support in substance abuse: Implications for mental health

and well-being. Psychiatry Research, 252, 1–8. https://doi.org/10.1016/j.psychres.2017.01.097
Brown, R. (2011). Prejudice: Its social psychology. Oxford: John Wiley and Sons.
Burns, J. K., Jhazbhay, K., & Emsley, R. (2011). Causal attributions, pathway to care and clinical features of first-episode psy-

chosis: A South African perspective. International Journal of Social Psychiatry, 57, 538–544. https://doi.org/10.1177/

0020764010390199
Cantor-Graae, E., & Selten, J. P. (2005). Schizophrenia and migration: A meta-analysis and review. American Journal of Psychi-

atry, 162, 12–24. https://doi.org/10.1176/appi.ajp.162.1.12
Conrad, M. M., & Pacquiao, D. F. (2005). Manifestation, attribution, and coping with depression among Asian Indi and from

the perspectives of health care practitioners. Journal of Transcultural Nursing, 16, 32–40. https://doi.org/10.1177/

1043659604271239

Corrigan, P., Markowitz, F. E., Watson, A., Rowan, D., & Kubiak, M. A. (2003). An attribution model of public discrimination

towards persons with mental illness. Journal of Health and Social Behavior, 44, 162–179. https://doi.org/10.2307/

1519806
Corrigan, P. W. (2000). Mental health stigma as social attribution: Implications for research methods and attitude change.

Clinical Psychology: Science and Practice, 7, 48–67. https://doi.org/10.1093/clipsy.7.1.48
Corrigan, P. W. (2012). A toolkit for evaluating programs meant to erase the stigma of mental illness. IL: Illinois Institute of Tech-

nology. Retrieved from:. https://www.scattergoodfoundation.org/sites/default/files/Evaluation%20Toolkit__

Corrigan.pdf
Corrigan, P. W., & Watson, A. C. (2002). Understanding the impact of stigma on people with mental illness. World Psychiatry,

1, 16–20.
Crisp, A. H., Gelder, M. G., Rix, S., Meltzer, H. I., & Rowlands, O. J. (2000). Stigmatisation of people with mental illnesses. The

British Journal of Psychiatry, 177, 4–7. https://doi.org/10.1192/bjp.177.1.4
Crocker, J., Major, B., & Steele, C. (1998). Social stigma. In S. Fiske, D. Gilbert, & G. Lindzey (Eds.), Handbook of social psychol-

ogy (pp. 504–553). Boston, MA: McGraw-Hill.
Fenton, S., & Sadiq-Sangster, A. (1996). Culture, relativism and the expression of mental distress: South Asian women in

Britain. Sociology of Health & Illness, 18, 66–85. https://doi.org/10.1111/1467-9566.ep10934418
Fernando, S. M., Deane, F. P., & McLeod, H. J. (2010). Sri Lankan doctors’ and medical undergraduates’ attitudes towards

mental illness. Social Psychiatry and Psychiatric Epidemiology, 45, 733-739.

Fritz, M. S., & MacKinnon, D. P. (2007). Required sample size to detect the mediated effect. Psychological Science, 18,

233–239. https://doi.org/10.1111/j.1467-9280.2007.01882.x
Garralda, E., & Raynaud, J. P. (2012). Brain, mind, and developmental psychopathology in childhood (Vol. 19). New York: Jason

Aronson.
Hayes, A. F. (2016). The PROCESS macro for SPSS and SAS. Retrieved from http://processmacro.org/download.html
Hornsey, M. J., & Hogg, M. A. (2000). Subgroup relations: A comparison of mutual intergroup differentiation and common

ingroup identity models of prejudice reduction. Personality and Social Psychology Bulletin, 26, 242–256. https://doi.org/

10.1177/0146167200264010
Huggett, C., Birtel, M. D., Awenat, Y. F., Fleming, P., Wilkes, S., Williams, S., & Haddock, G. (2018). A qualitative study: Expe-

riences of stigma by people with mental health problems. Psychology and Psychotherapy: Theory, Research and Practice,

91, 380–397. https://doi.org/10.1111/papt.12167
Islam, Z., Rabiee, F., & Singh, S. P. (2015). Black andminority ethnic groups’ perception and experience of early intervention

inpsychosis services in the United Kingdom. Journalof Cross-Cultural Psychology, 46, 737–753. https://doi.org/10.1177/

0022022115575737
Kapadia, D., Nazroo, J., & Tranmer, M. (2016). Ethnic differences in women’s use of mental health services: Do social net-

works play a role? Findings from a national survey. Ethnicity & Health, 23, 1–14. https://doi.org/10.1080/13557858.

2016.1263283
Kessler, R. C., Amminger, G. P., Aguilar-Gaxiola, S., Alonso, J., Lee, S., & Ustun, T. B. (2007). Age of onset of mental disorders:

A review of recent literature. Current Opinion in Psychiatry, 20, 359–364. https://doi.org/10.1097/YCO.

0b013e32816ebc8c

Kulhara, P., Avasthi, A., & Sharma, A. (2000). Magico-religious beliefs in schizophrenia: A study from North India. Psychopa-

thology, 33, 62–68. https://doi.org/10.1159/000029122
Lauber, C., & Rössler, W. (2007). Stigma towards people with mental illness in developing countries in Asia. International

Review of Psychiatry, 19, 157–178. https://doi.org/10.1080/09540260701278903
Link, B. G., Struening, E. L., Neese-Todd, S., Asmussen, S., & Phelan, J. C. (2001). Stigma as a barrier to recovery: The conse-

quences of stigma for the self-esteem of people with mental illness. Psychiatric Services, 52, 1621–1626. https://doi.

org/10.1176/appi.ps.52.12.1621

AHMED ET AL. 13AHMED ET AL. 211

Link, B. G., Struening, E. L., Rahav, M., Phelan, J. C., & Nuttbrock, L. (1997). On stigma and its consequences: Evidence from

a longitudinal study of men with dual diagnosis of mental illness and substance abuse. Journal of Health and Social Behav-
ior, 38, 177–190. https://doi.org/10.2307/2955424

Major, B., Mendes, W. B., & Dovidio, J. F. (2013). Intergroup relations and health disparities: A social psychological perspec-
tive. Health Psychology, 32, 514–524. https://doi.org/10.1037/a0030358

Major, B., & O’Brien, L. T. (2005). The social psychology of stigma. Annual Review of Psychology, 56, 393–421. https://doi.
org/10.1146/annurev.psych.56.091103.070137

McGorry, P. D., Killackey, E., & Yung, A. (2008). Early intervention in psychosis: Concepts, evidence and future directions.
World Psychiatry, 7, 148–156. https://doi.org/10.1002/j.2051-5545.2008.tb00182.x

McManus, S., Bebbington, P., Jenkins, R., & Brugha, T. (2016). Mental health and wellbeing in England: Adult psychiatric mor-
bidity survey 2014. Leeds: NHS digital.

Mirza, A., Birtel, M. D., Pyle, M., & Morrison, A. (2019). Cultural differences in psychosis: The role of causal beliefs and
stigma in White British and South Asians. Journal of Cross-Cultural Psychology, 50, 441–459. https://doi.org/10.1177/
0022022118820168

Naeem, F., Ayub, M., Javed, Z., Irfan, M., Haral, F., & Kingdon, D. (2006). Stigma and psychiatric illness. A survey of attitude
of medical students and doctors in Lahore, Pakistan. Journal of Ayub Medical College, Abbottabad, 18, 46–49.

Ng, C. H. (1997). The stigma of mental illness in Asian cultures. Australian and New Zealand Journal of Psychiatry, 31,
382–390. https://doi.org/10.3109/00048679709073848

NHS (2016). Implementing the early intervention in psychosis access and waiting time standard: Guidance. NHS England,
National Collaborating Centre for Mental Health, and NICE National Institute for Health and Care Excellence. Retrieved

from: https://www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/04/eip-guidance.pdf
NHS choices (2018). Psychosis. Retrieved from: https://www.nhs.uk/conditions/psychosis/
Nordt, C., Rössler, W., & Lauber, C. (2006). Attitudes of mental health professionals toward people with schizophrenia and

major depression. Schizophrenia Bulletin, 32, 709–714. https://doi.org/10.1093/schbul/sbj065
Office for National Statistics (2011). Census: Ethnic group, local authorities in the United Kingdom, 2011. London: Office for

National statistics.
Pawar, A. A., Peters, A., & Rathod, A. (2014). Stigma of mental illness. A study in the Indian Armed Forces. Medical Journal,

Armed Forces India, 70, 354–359. https://doi.org/10.1016/j.mjafi.2013.07.008
Perlick, D. A., Rosenheck, R. A., Clarkin, J. F., Sirey, J. A., Salahi, J., Struening, E. L., & Link, B. G. (2001). Stigma as a barrier to

recovery: Adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar affective disorder.

Psychiatric Services, 52, 1627–1632. https://doi.org/10.1176/appi.ps.52.12.1627
Pettigrew, T. F., & Tropp, L. R. (2006). A meta-analytic test of intergroup contact theory. Journal of Personality and Social Psy-

chology, 90, 751–783. https://doi.org/10.1037/0022-3514.90.5.751
Phelan, J. C., Link, B. G., Stueve, A., & Pescosolido, B. A. (2000). Public conceptions of mental illness in 1950 and 1996: What

is mental illness and is it to be feared? Journal of Health and Social Behavior, 41, 188–207. https://doi.org/10.2307/
2676305

Public Health England (2016. Psychosis data report. Retrieved from: https://assets.publishing.service.gov.uk/government/
uploads/system/uploads/attachment_data/file/611422/Psychosis_data_report.pdf

Rathod, S., Kingdon, D., Phiri, P., & Gobbi, M. (2010). Developing culturally sensitive cognitive behaviour therapy for psycho-

sis for ethnic minority patients by exploration and incorporation of service users’ and health professionals’ views and
opinions. Behavioural and Cognitive Psychotherapy, 38, 511–533. https://doi.org/10.1017/S1352465810000378

Reinke, R. R., Corrigan, P. W., Leonhard, C., Lundin, R. K., & Kubiak, M. A. (2004). Examining two aspects of contact on the
stigma of mental illness. Journal of Social and Clinical Psychology, 23, 377–389. https://doi.org/10.1521/jscp.23.3.377.
35457

Rosenfield, S. (1997). Labeling mental illness: The effects of received services and perceived stigma on life satisfaction.
American Sociological Review, 62, 660–672. https://doi.org/10.2307/2657432

Rüsch, N., Angermeyer, M. C., & Corrigan, P. W. (2005). Mental illness stigma: Concepts, consequences, and initiatives to
reduce stigma. European Psychiatry, 20, 529–539. https://doi.org/10.1016/j.eurpsy.2005.04.004

Salve, H., Goswami, K., Sagar, R., Nongkynrih, B., & Sreenivas, V. (2013). Perception and attitude towards mental illness in

an urban community in South Delhi–A community based study. Indian Journal of Psychological Medicine, 35, 154–158.
https://doi.org/10.4103/0253-7176.116244

Schomerus, G., & Angermeyer, M. C. (2008). Stigma and its impact on help-seeking for mental disorders: What do we know?
Epidemiology and Psychiatric Sciences, 17, 31–37. https://doi.org/10.1017/S1121189X00002669

Schulze, B., & Angermeyer, M. C. (2003). Subjective experiences of stigma. A focus group study of schizophrenic patients,

their relatives and mental health professionals. Social Science & Medicine, 56, 299–312. https://doi.org/10.1016/S0277-
9536(02)00028-X

StataCorp, L. P. (2013). Stata power and sample-size reference manual.

14 AHMED ET AL.212 AHMED ET AL.

Steele, C. M., Spencer, S. J., & Aronson, J. (2002). Contending with group image: The psychology of stereotype and social

identity threat. In Advances in experimental Social Psychology (Vol. 34) (pp. 379–440). San Diego, CA, US: Academic
Press.

Tabassum, R., Macaskill, A., & Ahmad, I. (2000). Attitudes towards mental health in an urban Pakistani community in the
United Kingdom. International Journal of Social Psychiatry, 46, 170–181. https://doi.org/10.1177/
002076400004600303

Thornicroft, G., Rose, D., Kassam, A., & Sartorius, N. (2007). Stigma: Ignorance, prejudice or discrimination? The British Jour-
nal of Psychiatry, 190, 192–193. https://doi.org/10.1192/bjp.bp.106.025791

Van Boekel, L. C., Brouwers, E. P., Van Weeghel, J., & Garretsen, H. F. (2013). Stigma among health professionals towards
patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug and Alcohol
Dependence, 131, 23–35. https://doi.org/10.1016/j.drugalcdep.2013.02.018

Vezzali, L., & Stathi, S. (2017). Intergroup contact theory: Recent developments and future directions. New York, NY: Taylor &
Francis.

Vos, T., & Begg, S. (2003). Victorian burden of disease study: Morbidity. Melbourne: Public Health Division, Department of
Human Services. Retrieved from:. https://www2.health.vic.gov.au/about/publications/researchandreports/Victorian-
Burden-of-Disease-Study

West, K., Hewstone, M., & Lolliot, S. (2014). Intergroup contact and prejudice against people with schizophrenia. The Journal
of Social Psychology, 154, 217–232. https://doi.org/10.1080/00224545.2014.888327

Wood, L., Birtel, M., Alsawy, S., Pyle, M., & Morrison, A. (2014). Public perceptions of stigma towards people with schizo-
phrenia, depression, and anxiety. Psychiatry Research, 220, 604–608. https://doi.org/10.1016/j.psychres.2014.07.012

Wright, E. R., Gronfein, W. P., & Owens, T. J. (2000). Deinstitutionalization, social rejection, and the self-esteem of former
mental patients. Journal of Health and Social Behavior, 41, 68–90. https://doi.org/10.2307/2676361

Zanna, M. P., & Rempel, J. K. (1988). Attitudes: A new look at an old concept. In D. Bar-Tal, & A. W. Kruglanski (Eds.), The
Social Psychology of Knowledge (pp. 315–334). Cambridge, UK: Cambridge University Press.

How to cite this article: Ahmed S, Birtel MD, Pyle M, Morrison AP. Stigma towards psychosis: Cross-

cultural differences in prejudice, stereotypes, and discrimination in White British and South Asians. J

Community Appl Soc Psychol. 2019;1–15. https://doi.org/10.1002/casp.2437

AHMED ET AL. 15

cultural differences in prejudice, stereotypes, and discrimination in White British and South Asians.

J Community Appl Soc Psychol. 2020;30:199–213. https://doi.org/10.1002/casp.2437

AHMED ET AL. 213