View metadata, citation and similar papers at core.ac.uk brought to you by CORE provided by Middlesex University Research Repository Stigma towards people with mental health problems: An individualism-collectivism cross-cultural comparison A thesis submitted to Middlesex University in partial fulfilment of the requirements for the degree of Doctor of Philosophy Chris Papadopoulos School of Health and Social Sciences, Middlesex University December, 2009 Contents Acknowledgements VI List of tables VII List of figures X Abstract XI Chapter 1: Introduction 1.1 Background of the study 1 1.2 Aims and objectives 7 1.3 Hypothesis 8 Chapter 2: Literature review 2.1 Stigma: The concept 11 2.2 The impact of mental health stigma 15 2.3 Stigma and attitudes to mental health problems in various cultures 19 2.3.1 China 20 2.3.2 Greece/Cyprus 22 2.3.3 America 25 2.3.4 United Kingdom 31 2.4 Individualism-collectivism 36 2.4.1 Geert Hofstede 36 2.4.2 Michael Bond 41 2.4.3 Harry Triandis 42 2.5 The history of individualism-collectivism 48 2.6 The emergence of the individualism-collectivism paradigm 57 2.7 Individualism-collectivism as an explanatory model 60 2.7.1 In-groups/out-groups 60 2.7.2 Self-definition 61 2.7.3 Emotions and emotional expression 63 2.8 Evaluation of the individualism-collectivism paradigm 65 2.9 Culture 67 2.9.1 The Chinese cultural orientation 75 2.9.2 The Greek/Greek Cypriot cultural orientation 80 2.9.3 The American cultural orientation 83 2.9.4 The British cultural orientation 87 Chapter 3: Methodology 3.1 Study design 91 3.1.1 Epistemology 92 3.1.2 Methods 97 3.1.2.1 Quantitative method 97 3.1.2.1.1 Questionnaire data collection style 98 3.1.2.1.2 Questionnaire translation 99 3.1.2.2 Qualitative method 101 3.2 Sampling methods 101 3.3 Ethical considerations 108 3.3.1 Informed consent 108 II 3.3.2 Anonymity and confidentiality 110 3.3.3 Interview ethics 111 3.4 Data collection tools 112 3.4.1 The questionnaire 113 3.4.2 Semi-structured interviews 116 3.5 Pilot 118 3.6 Data collection procedure 123 3.6.1 Quantitative survey 124 3.6.2 Qualitative interviews 125 3.7 Data analysis 126 3.7.1 Quantitative data analysis 126 3.7.2 Qualitative data analysis 128 Chapter 4: Results 4.1 Quantitative results 131 4.1.1 Socio-demographic details 131 4.1.2 Stigmatisation levels within cultural groups 138 4.1.2.1 Main stigmatisation explanatory factors within white-English 141 culture (excluding individualism-collectivism) 4.1.2.2 Main stigmatisation explanatory factors within American culture 145 (excluding individualism-collectivism) 4.1.2.3 Main stigmatisation explanatory factors within the Greek/Greek 149 Cypriot culture (excluding individualism-collectivism) 4.1.2.4 Main stigmatisation explanatory factors within the Chinese culture 151 (excluding individualism-collectivism) 4.1.3 Individualism-collectivism scores: association with cultural groups 156 and CAMI constructs 4.1.4 Individualism-collectivism logistic regression test results 161 4.2 Qualitative results 165 4.2.1 Interviewees 165 4.2.2 Main themes 165 4.2.2.1 Individualism 167 4.2.2.1.1 Key attributes of individualism 168 4.2.2.1.2 Potential consequences of white-English and American individualism 175 4.2.2.1.3 Causes and antecedents of American and English individualism 180 4.2.2.2 Collectivism 185 4.2.2.2.1 Key attributes of collectivism 186 4.2.2.2.2 Potential consequences of collectivism 194 4.2.2.2.3 Causes and antecedents of Chinese and Greek/Greek Cypriot 200 collectivism 4.2.2.3 Mental health attitudes and stigma 203 4.2.2.3.1 Mental health attitudes and stigma in the American culture 204 4.2.2.3.2 Mental health attitudes and stigma in the English culture 210 4.2.2.3.3 Mental health attitudes and stigma in the Chinese culture 214 4.2.2.3. 4 Mental health attitudes and stigma in the Greek/Greek Cypriot culture 218 4.2.2.4 Immigration 223 4.2.2.4.1 American immigration and cultural identity affect 224 4.2.2.4.2 Chinese immigration and cultural identity affect 227 4.2.2.4.3 Greek/Greek Cypriot immigration and cultural identity affect 229 III Chapter 5: Discussion 5.1 Introduction 233 5.2.1 Greek/Greek Cypriot and Chinese mental health attitudes level and type 234 5.2.2 What factors (excluding individualism-collectivism) explain mental health 238 attitudes? An examination of Greek/Greek Cypriot cultural group 5.2.3 What factors (excluding individualism-collectivism) explain mental health 242 attitudes? An examination of the Chinese cultural group 5.2.4 American and white-English mental health attitudes level and type 245 5.2.5 What factors (excluding individualism-collectivism) explain mental health 252 attitudes? An examination of the American cultural group 5.2.6 What factors (excluding individualism-collectivism) explain mental health 256 attitudes? An examination of the white-English culture 5.3 Individualism-collectivism as an explanatory factor of mental health stigma 260 5.3.1 The interrelated roles of community surveillance, ruralism/urbanism, 265 conservatism/liberalism, and traditionalism/modernism in understanding mental health stigma 5.4 An examination of the American, English, Greek/Greek Cypriot, and Chinese 273 sampled cultures 5.4.1 The American and English cultures and their VHIC value orientations 274 5.4.2 The Chinese and Greek/Greek Cypriot cultures and their VHIC value orientations 285 Chapter 6: Conclusion 6.1 Introduction 294 6.2 The main findings: Their contributions and implications 294 6.3 Policy and clinical recommendations 303 6.3.1 Policy recommendations 303 6.3.2 Clinical recommendations 305 6.4 Future research 306 6.5 Study limitations and critical considerations 307 6.6 Brief conclusion 311 References 313 Appendices 369 IV Acknowledgements I would like to express my deepest gratitude to my supervisors: Dr. John Foster and Dr. Kay Caldwell, who have both provided invaluable constructive feedback and much needed encouragement. I found their academic, professional, but also friendly and open approach enormously beneficial. My grateful thanks also go to all the research participants who gave up their time to help me with my studies. I am also indebted to Middlesex University for providing much needed funding. I also must acknowledge Dr. Gerry Leavey for having faith in me at a young age and teaching me all there is to know about research and academia (good and bad!), while simultaneously being a great role model for me. I should also thank my closest friends: Andy, Antony, and Harry, who have helped me to stay sane for the last five years (often without knowing it) despite each of them paradoxically lacking in sanity. Finally, I cannot thank enough the wisdom and unconditional love given to me by all of my family, particularly from my mum who has invaluably helped me each step of the way, as she and my dad have done all of my life. This thesis could also not have been possible without the support and love of my wife who continuously keeps me invigorated with life and has the almost magical ability to put a smile on my face no matter what the scenario. Thank you all. V List of tables 2.1 Differences between collectivists and individualists (adapted from Hofstede, 1997) 2.2 Individualism index values for 50 countries and 3 regions (Hofstede, 2008) 2.3 Attributes defining individualism and collectivism and their antecedents and consequents (Triandis et al, 1990) 2.4 Characteristics of vertical and horizontal individualism and collectivism (Singelis et al, 1995) 2.5 Various key authors’ definitions of culture 4.1 Socio-demographic details of survey participants 4.2 Survey participants’ religiousness level across cultural groups by age groups 4.3 Religious affiliation breakdown of survey participants 4.4 Ethnic breakdown of survey participants 4.5 Cultural group CAMI construct scores 4.6 Non-UK-born Greek/Greek Cypriots and Chinese vs. UK-born Greek/Greek Cypriots and Chinese vs. CAMI construct scores 4.7 Factors associated with CAMI constructs within the white-English cultural Group 4.8 Logistic regression statistics of significant independent predictors associated with CAMI constructs within the white-English cultural group 4.9 Factors associated with CAMI constructs within the American cultural group 4.10 Higher and lower UK-living lifetime percentage in American group vs other cultural groups vs. CAMI median scores 4.11 Logistic regression statistics of significant independent predictors associated VI with CAMI constructs within the American cultural group 4.12 Factors associated with CAMI constructs within the Greek/Greek Cypriot cultural group 4.13 Factors associated with CAMI constructs within the Chinese cultural group 4.14 Mental health knowledge scores vs. cultural group 4.15 Mental health experience scores vs. cultural group 4.16 Mental health experience and knowledge bivariate correlation test vs. cultural group 4.17 Logistic regression statistics of significant independent predictors associated with CAMI measures within the Chinese cultural group 4.18 Individualism-collectivism scores vs. cultural group 4.19 VHIC Cronbach’s Alpha-coefficient reliability analysis results 4.20 Spearman’s rho correlation tests between I/C and the CAMI inventory within cultural groups 4.21 Differences in unaccounted-for variance (-2LL) and overall model predictive power (NR²) between regression tests that included and excluded individualism-collectivism (I/C) as an explanatory factor in the American and Chinese cultural groups 4.22 Logistic regression model statistics of significant independent predictors associated with CAMI measures within the