Psychological Services In the public domain

2014, Vol. 11, No. 1, 105–113 DOI: 10.1037/a0032780

Endorsed and Anticipated Stigma Inventory (EASI): A Tool for Assessing

Beliefs About Mental Illness and Mental Health Treatment Among Military
Personnel and Veterans

Dawne Vogt Brooke A. L. Di Leone and Joyce M. Wang

National Center for Posttraumatic Stress Disorder, VA Boston National Center for Posttraumatic Stress Disorder, VA Boston
Healthcare System, Boston, Massachusetts and Boston Healthcare System, Boston, Massachusetts
University School of Medicine

Nina A. Sayer Suzanne L. Pineles

Minneapolis VA Health Care System, Minneapolis, Minnesota National Center for Posttraumatic Stress Disorder, VA Boston
and University of Minnesota, Minneapolis Healthcare System, Boston, Massachusetts and Boston
University School of Medicine

Brett T. Litz
Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System,
Boston, Massachusetts and Boston University School of Medicine

Many military personnel and veterans who would benefit from mental health treatment do not seek care,
underscoring the need to identify factors that influence initiation and retention in mental health care. Both
endorsed and anticipated mental health stigma may serve as principal barriers to treatment seeking. To
date, most research on mental health stigma in military and veteran populations has relied on nonvali-
dated measures with limited content coverage and confounding in the assessment of different domains of
mental health stigma. This article describes the development and psychometric evaluation of the
Endorsed and Anticipated Stigma Inventory (EASI), which was designed to assess different dimensions
of stigma-related beliefs about mental health among military and veteran populations. Findings based on
a national sample of U.S. veterans deployed in support of Operation Enduring Freedom (OEF) in
Afghanistan or Operation Iraqi Freedom (OIF) in Iraq suggest that the EASI is a psychometrically sound
instrument. Specifically, results revealed evidence for the internal consistency reliability, content valid-
ity, convergent and discriminant validity, and discriminative validity of EASI scales. In addition,
confirmatory factor analysis results supported the proposed factor structure for this inventory of scales.

Keywords: stigma, barriers to care, VA health care use, veterans, military

Servicemembers are at risk for a range of mental health prob-
lems due to their potential exposure to traumatic events during
deployment. For example, findings indicate that a substantial mi-
nority of servicemembers deployed in support of the recent wars in
Afghanistan and Iraq report symptoms consistent with posttrau-
matic stress disorder (PTSD), depression, and alcohol abuse after
returning from deployment (Hoge et al., 2004; Kang & Hyams,
2005; Lapierre, Schwegler, & LaBauve, 2007; Milliken, Auchter-
lonie, & Hoge, 2007). Despite the relatively high availability of
free or low-cost mental health services in both military and De-
partment of Veterans Affairs (VA) health care settings, many
servicemembers and veterans who might benefit from treatment do
not make use of available mental health services. For example, in
a national sample of veterans deployed in support of Operation

This article was published Online First November 25, 2013.
Dawne Vogt, Women’s Health Sciences Division, National Center for Post-
traumatic Stress Disorder, VA Boston Healthcare System, Boston, Massachusetts,
and Department of Psychiatry, Boston University School of Medicine; Brooke
A. L. Di Leone and Joyce M. Wang, Women’s Health Sciences Division, National
Center for Posttraumatic Stress Disorder, VA Boston Healthcare System; Nina A.
Sayer, Center for Chronic Disease Outcomes Research, Minneapolis VA Health
Care System, Minneapolis, Minnesota, and Departments of Medicine and Psychi-
atry, University of Minnesota, Minneapolis; Suzanne L. Pineles, Women’s Health
Sciences Division, National Center for Posttraumatic Stress Disorder, VA Boston
Healthcare System and Department of Psychiatry, Boston University School of
105
Medicine; Brett T. Litz, Massachusetts Veterans Epidemiology Research and
Information Center, VA Boston Healthcare System and Department of Psychiatry,
Boston University School of Medicine.
This research was supported, in part, by a Department of Veterans
Affairs Health Sciences Research and Development Service grant (DHI
06-225-2; Gender, Stigma, and Other Barriers to VHA Use for OEF/OIF
Veterans; Principal Investigator: Dawne Vogt, PhD).
Correspondence concerning this article should be addressed to Dawne S.
Vogt, PhD, National Center for Posttraumatic Stress Disorder (116B-3),
VA Boston Healthcare System, 150 South Huntington Avenue, Boston,
MA 02130. E-mail: dawne.vogt@va.gov
106 VOGT, DI LEONE, WANG, SAYER, PINELES, AND LITZ
Enduring Freedom (OEF; Afghanistan) or Operation Iraqi Free-
dom (OIF; Iraq), nearly half (47%) of individuals with probable
posttraumatic stress disorder (PTSD) or major depression had not
received any mental health care in the previous year and only 30%
of those who had initially sought care reported having received a
minimally adequate amount of care (Schell & Marshall, 2008).
Consequently, it is important for administrators, decision-makers,
leaders, and clinicians to identify and understand the factors that
influence initiation and retention in mental health treatment among
military and veteran populations.
A review of the broader literature suggests two key facets of
stigma that may influence treatment seeking. The first facet, re-
ferred to as endorsed stigma, is a key component of the self-stigma
process that reflects the extent to which an individual has incor-
porated negative beliefs about the stigmatizing attribute (in this
case, beliefs about mental illness and mental health treatment) into
his or her own personal belief system (Corrigan & Rao, 2012;
Link, 1987). The second facet, which draws from Corrigan and
colleagues’ extensive body of work on public stigma related to
mental illness (e.g., Corrigan, 2004; Corrigan & Rusch, 2002) and
is referred to as anticipated stigma, reflects the extent to which an
individual anticipates that he or she will be devalued or discredited
by others in the community for having the stigmatized attribute
(Earnshaw & Chaudoir, 2009; Earnshaw & Quinn, 2012; Markow-
itz, 1998).
Although the military and veteran literature on mental health
stigma is somewhat more limited than the broader civilian litera-
ture, there is reason to believe that stigma may be an especially
powerful deterrent to service use among military and veteran
populations. Specifically, it has been suggested that the high value
placed on competence, confidence, and “emotional toughness” in
the military may contributed to increased stigma in these popula-
tions (Nash, Silva, & Litz, 2009; Sayer et al., 2009). Moreover, the
military includes a large proportion of young men, a group that has
been found to be especially uncomfortable with acknowledging
mental health problems and seeking care (Addis & Mahalik, 2003;
Greene-Shortridge, Britt, & Castro, 2007; Mojtabai, Olfson, &
Mechanic, 2002; Porter & Johnson, 1994).
Despite the potential relevance of both forms of stigma, research
on military and veteran populations has focused nearly exclusively
on anticipated stigma as a barrier to care, paying far less attention
to the role of self-stigma in service use (Vogt, 2011). The lack of
research on this topic may be accounted for, at least in part, by the
lack of validated measures designed to assess different compo-
nents of self-stigma that are relevant for these populations. As a
consequence, most military and veteran research to date has relied
on brief, nonvalidated measures that do not provide a broad as-
sessment of stigma-related barriers to care or that confound the
assessment of different stigma components within a single scale
(Vogt, 2011). Another limitation is the lack of scales that assess
stigma independent of its perceived impact on service use. Find-
ings based on measures that require respondents to evaluate the
impact that stigma has on their service use, such as the widely used
Perceived Stigma and Barriers to Care for Psychological Problems
scale (Britt, 2000), are important in their ability to highlight the
extent to which servicemembers and veterans perceive stigma as a
barrier to care. However, some individuals may not feel comfort-
able acknowledging or not even realize the role that their own or
others’ biases about mental illness play in their willingness to seek
mental health care (Vogt, 2011). Therefore, the field would also
benefit from the availability of measures that address perceptions
of stigma independent of its perceived impact on treatment seek-
ing.
To address this gap, we developed and validated an instrument
that assesses a broad range of mental health beliefs that may have
implications for servicemembers’ and veterans’ use of mental
health care. Specifically, this instrument, called the Endorsed and
Anticipated Stigma Inventory (EASI) builds on prior conceptual-
izations of stigma put forth in the literature and addresses both
personal beliefs about mental illness and mental health treatment
(i.e., endorsed stigma) and concerns about being stigmatized by
others for having a mental health problem (i.e., anticipated
stigma). In the instrument development phase (Part 1), we defined
the stigma constructs that were the focus of this project and
operationalized these constructs via initial item development. In
Part 2, we examined the item and scale characteristics of the
resulting scales. Part 3 was an examination of evidence for con-
vergent and discriminant validity, as well as the smaller literature
on mental health stigma in discriminative validity. Part 4 was an
examination of the factor structure of the instrument using confir-
matory factor analyses.
Method and Results
Part 1: Instrument Development
Defining the target construct and its content domains. We
used a rational approach to test construction that emphasized
content validity (Haynes, Richard, & Kubany, 1995; Jackson,
1971; Nunnally & Bernstein, 1994). Our first step in the develop-
ment of the EASI was to clearly define the core components of the
targeted stigma constructs and elaborate on their content domains.
Our initial conceptualization of stigma-related beliefs about mental
illness and mental health treatment in military and veteran popu-
lations drew from the broader literature on stigma (e.g., Cooper,
Corrigan, & Watson, 2003; Corrigan, 2004; Corrigan & Rusch,
2002; Earnshaw & Chaudoir, 2009; Earnshaw & Quinn, 2012;
Leaf, Bruce, & Tischler, 1986; Link & Phelan, 2001; Mansfield,
Addis, & Courtenay, 2005; Sirey et al., 2001), as well as the more
limited literature on mental health stigma among members of the
military and veterans (e.g., Britt, 2000; Britt et al., 2008; Greene-
Shortridge et al., 2007; Pietrzak, Johnson, Goldstein, Malley, &
Southwick, 2009).
Synthesizing what have largely been separate research areas, we
identified three potential components of endorsed stigma that may
be especially salient for military and veteran populations. These
components include: (a) beliefs about mental illness (Brown, 2008;
Corrigan, Lickey, Campion, & Rashid, 2000; Day, Edgren, &
Eshleman, 2007; Link, Phelan, Bresnahan, Stueve, & Pescosolido,
1999); (b) beliefs about mental health treatment (Leaf et al., 1986;
Pirkis, Blood, Francis, & McCallum, 2006); and (c) beliefs about
help-seeking for mental health problems (Mansfield et al., 2005;
Ojeda & Bergstresser, 2008; Perlick & Manning, 2006; Waldron,
1997). As conceptualized in this measure, content domains within
the beliefs about mental illness construct reflect beliefs about the
character and competence of people with mental health problems,
as well as one’s level of comfort interacting with people with
mental illness. Content domains in the beliefs about mental health
 ENDORSED AND ANTICIPATED STIGMA INVENTORY
treatment construct include beliefs about talk therapy, medication,
and mental health providers. Content domains in the beliefs about
help-seeking construct include beliefs about the legitimacy of
seeking help for mental health problems, as well as level of
comfort with being in the “patient” role.
Based on our review of this literature, we identified two general
components of anticipated stigma related to mental health problems:
(a) concern about stigma from loved ones, and (b) concern about
stigma in the workplace. Content domains within the concern about
public stigma from loved ones construct reflect individuals’ beliefs
about the consequences of having a mental health problem for family
members’ and friends’ level of comfort being around them and
perceptions of their character and competence. Content domains
within the concern about stigma in the workplace construct reflect
individuals’ beliefs about the consequences of having a mental health
problem for supervisors’ and coworkers’ level of comfort being
around them and perceptions of their character and competence, as
well as potential career consequences. Although concerns about
stigma from loved ones are likely to be relevant for both current and
former military personnel, concerns about mental health stigma in the
workplace may be an especially salient barrier to care for current
military personnel given the negative consequences that having a
mental health problem may have on servicemembers’ military ca-
reers.
Item development. Guided by the above definitions, and with
ongoing reference to the broader literature, we developed an initial
pool of items to reflect the content of each of these core components:
(a) beliefs about mental illness, (b) beliefs about mental health treat-
ment, (c) beliefs about treatment-seeking, (d) concerns about stigma
from loved ones, and (e) concerns about stigma in the workplace.
Items were framed as statements (e.g., “If I had a mental health
problem and family/friends knew about it, they would think less of
me”) and a 5-point Likert-type response format, ranging from 1
(strongly disagree) to 5 (strongly agree) was selected to allow re-
spondents to indicate their level of agreement with each statement. No
reverse-scored items were included, but positively phrased filler items
(e.g., “If I had a mental health problem and family/friends knew about
it, they would be supportive of me”) were included to reduce nega-
tivity bias. Scales were scored so that higher scores were indicative of
greater stigma in each of the domains assessed in this inventory of
scales.
A table of specifications (Aiken, 1994) was developed to identify
key domains within each component and aid in the orderly construc-
tion of item statements or questions across content areas. More spe-
cifically, different aspects of each component were identified, and
items were written to systematically represent each content domain.
The initial item sets along with the formal definition from which they
were derived were reviewed by content and psychometric experts.
Table 1
Item and Scale Characteristics of the EASI
Variable n Mean
Beliefs about mental illness 677
Beliefs about mental health treatment 676
Beliefs about treatment seeking 681
Concerns about stigma from loved ones 672
Concerns about stigma in the workplace 679
107
Experts were asked to provide judgments regarding the content sat-
uration of each item with respect to its content domain and to identify
items that were confusing, poorly written, or had overlapping content.
In cases where redundancy was identified, the item that was judged as
most comprehensible and concise was retained. The end result of
these steps was a newly refined pool of eight items per component, all
clearly expressed and heavily saturated with the desired content.
Given that military personnel are typically required to have at least a
high school diploma, items were targeted to a high school grade level.
An examination of the scale’s readability confirmed that all scales
were appropriate for use with samples that have completed at least a
ninth-grade education. Specifically, the Flesch-Kincaid Grade Level
score (Flesch, 1949) was 7.2 for the Beliefs about Mental Illness scale,
8.4 for the Beliefs about Mental Health Treatment scale, 6.7 for the
Beliefs about Treatment Seeking scale, 8.3 for the Concerns about
Stigma from Loved Ones scale, and 9.1 for the Concerns about
Stigma in the Workplace scale.
Part 2: Initial Item and Scale Analyses
Using data generated from a national mail survey of OEF/OIF
veterans, we first calculated frequency distributions and examined
skewness and kurtosis for all items in the EASI. Next, we computed
classical-test-theory-oriented item and scale characteristics (Aiken,
1994; Anastasi, 1988; Nunnally & Bernstein, 1994), with the goal of
identifying any items that detracted from reliability and should be
considered for elimination. Once item sets were finalized, means,
standard deviations, and ranges were calculated for each scale (see
Table 1).
Participants. The emphasis in instrument development is to
achieve a sample that has broad dispersion on the attributes that are
the focus of the psychometric inquiry and ample representation of the
kinds of persons for whom the instrument is intended (Nunnally &
Bernstein, 1994). Potential participants were randomly selected from
a Defense Manpower Data Center (DMDC) roster of all U.S. OEF/
OIF veterans who had experienced a deployment in support of either
OEF or OIF, and were separated from military service at the time of
the survey. All participants had returned from deployment between
January 2007 and January 2009. To allow for gender-stratified anal-
yses, the sample was stratified on gender (50% men, 50% women). A
modification of the Dillman, Smyth, and Christian (2009) mail survey
procedure was used for data collection, involving up to five contacts
and a $20 prepaid gift card incentive in the first mailing of the survey.
Of 2,950 potential participants, 461 could not be located and 17
responded to indicate that they were ineligible for the study (i.e., not
OEF/OIF veterans). Among the remaining 2,472 individuals believed
to have received the survey, 707 returned completed surveys for a
response rate of 29%. We compared survey responders with nonre-
SD Range Alpha
18.13 5.65 8–34 .86
19.43 5.43 8–37 .84
21.17 6.85 8–40 .86
18.56 7.59 8–39 .92
23.81 7.56 8–40 .93
108 VOGT, DI LEONE, WANG, SAYER, PINELES, AND LITZ
sponders on demographic and military characteristics drawn from
DMDC data to explore potential nonresponse bias. Overall, findings
revealed few differences and those differences that were observed
were generally small and unlikely to influence the specific associa-
tions under examination in this study. Differences between responders
and nonresponders were small with regard to gender (Cramer’s ␾ ⫽
⫺0.11), age (r ⫽ .190) race (Cramer’s ␾ ⫽ ⫺0.041), military rank
(Cramer’s V ⫽ 0.146), education (Cramer’s ␾ ⫽ 0.187), marital status
(Cramer’s ␾ ⫽ ⫺.071), military branch (Cramer’s V ⫽ 0.079), and
duty status (Cramer’s ␾ ⫽ 0.005). Of the 707 respondents who
provided completed surveys, 702 veterans who had returned their
surveys prior to the initiation of this study were included in the current
analyses.
The sample was composed of 57% women and 43% men, and was
primarily Caucasian (66%), with 16% identifying as African Ameri-
can. The mean age was 37.52 (SD ⫽ 9.99), and 40% of participants
reported having a college degree. Approximately 79% were deployed
from Active Duty and 21% were from the National Guard or Reserve
components. Veterans from all branches of service were included:
Army (50%), Air Force (24%), Navy (18%), and Marines (8%).
Further details about this sample and the methodology are available
from the first author.
Results. Calculation of frequency distributions and examination
of skewness and kurtosis in the full sample revealed no problems with
dispersion on these items. Thus, we next examined estimates of
internal consistency reliability and associated statistics for each scale.
As indicated in the last column of Table 1, internal consistency
reliability estimates for all scales exceeded .80 and were, therefore,
considered acceptable. Item-total correlation values were also all
acceptable, with values of at least .40 for all items within each scale,
exceeding the minimum threshold for acceptability (i.e., .30; Nun-
nally & Bernstein, 1994). Specifically, item-total correlation values
ranged from .47 to .75 for the Beliefs about Mental Illness scale
(average value ⫽ .61), .43 to .70 for the Beliefs about Mental Health
Treatment Scale (average value ⫽ .58), .46 to .71 for the Beliefs about
Treatment Seeking scale (average value ⫽ .61), .66 to .80 for the
Concerns about Stigma from Loved Ones scale (average value ⫽ .72),
.60 to .84 for the Concerns about Stigma in the Workplace scale
(average value ⫽ .76). Together, these findings provide evidence for
the internal consistency reliability of the scales included in the EASI.
Part 3: Evidence for Validity
Having created a content-saturated and internally consistent inven-
tory of endorsed and anticipated stigma scales (see Appendix for the
40-item EASI), we next turned attention to examining evidence for
the validity of this measure based on the same sample of OEF/OIF
veterans. Associations among the three endorsed stigma scales and
two anticipated stigma scales were examined to confirm their con-
vergent validity. Associations between the endorsed and anticipated
scales were examined to confirm their discriminant validity. Further
evidence of discriminant validity was sought in terms of the associ-
ation between these scales and a measure of social desirability. A final
set of analyses was conducted to examine the discriminative validity
of these scales with respect to mental health symptomatology, as it is
well-established that individuals with mental health problems report
more stigma-related concerns than those without mental health prob-
lems (e.g., Hoge et al., 2004). Specifically, analyses examined
whether individuals with and without probable PTSD, depression, and
alcohol abuse differed on the stigma scales.
Additional Measures
Marlowe-Crowne Social Desirability Scale (Crowne & Mar-
lowe, 1960). A 13-item instrument (␣ ⫽. 84) was used to mea-
sure an individual’s tendency to describe himself/herself favorably
or in a socially desirable manner. Scores were computed as the
number of item responses in the keyed direction based on a
true/false like response like response format. Higher scores indi-
cate more social desirability. Sample items are “I have never
intensely disliked anyone,” “I sometimes feel resentful when I
don’t get my way,” and “There have been occasions when I took
advantage of someone” (reverse scored). The estimate of internal
consistency reliability for this scale was .79 in the current sample.
PTSD Checklist–Military Version (PCL; Weathers, Litz,
Herman, Huska, & Keane, 1993). The PCL was used to assess
posttraumatic stress symptomatology related to stressful deployment
experiences. The 17 items are directly adapted from the Diagnostic
and Statistical Manual of Mental Disorders (DSM–IV; American
Psychiatric Association, 1994) to assess reexperiencing, avoidance
and emotional numbing, and hyperarousal symptoms. Respondents
were asked to rate how much they have been bothered by each
symptom in the past 6 month. Coefficient alpha was .97 in the current
sample. Based on commonly used criteria for classifying probable
PTSD among OEF/OIF veterans (Tanielian & Jaycox, 2008), those
who had a minimum score of 50 (139 participants, 21% of total
sample) were identified as having probable PTSD.
Beck Depression Inventory–Primary Care (Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961). An adapted version of
the 7-item Beck Depression Inventory-Primary Care was used to
index depression symptoms (Beck, Steer, Ball, Ciervo, & Kabat,
1997). This measure consists of seven statements extracted from the
original Beck Depression Inventory (Beck et al., 1961) but with a
variation in the response format; unlike the original Beck instrument,
each item is rated on a 5-point scale, with anchors ranging from 1 ⫽
strongly disagree to 5 ⫽ strongly agree. Sample items include “In the
last 6 months, I have felt like a failure,” and “In the last 6 months, I
have had thoughts of killing myself.” Scores on the original Beck
Depression Inventory have correlated well with clinicians’ judgments
of depression intensity (Beck, Steer, & Garbin, 1988). The coefficient
alpha for this brief form of the measure is .91. The standard, empir-
ically tested cut-off for the BDI-PC is a score of 4 for maximum
clinical efficiency, specificity, and sensitivity (Beck et al., 1997; Steer,
Cavalieri, Leonard, & Beck, 1999). Based on a commensurate cut-off
to the BDI-PC’s score of 4, those who endorsed a 4 or greater on at
least four of the seven items (263 participants, 39%) were classified as
having probable depression.
CAGE. The CAGE (Ewing, 1984) is a 4-item questionnaire that
assesses the presence of clinically significant alcohol use. A correla-
tion of .89 has been shown between CAGE scores and diagnoses
when using the dichotomous, two-item cutoff method for scoring
(Bradley, Kivlahan, Bush, McDonell, & Fihn, 2001). Coefficient
alpha was .68 in the current sample. Based on commonly used criteria
for classifying probable alcohol abuse (Buchsbaum, Buchanan, Cen-
tor, Schnoll, & Lawton, 1991), those who had a minimum score of 2
(106 participants, 16%) were identified as having probable alcohol
abuse.
 ENDORSED AND ANTICIPATED STIGMA INVENTORY
Results. As indicated in Table 2, none of the correlations among
either endorsed or anticipated stigma scales exceeded .70, suggesting
that each scale addresses unique content (Kline, 2005). The highest
correlation was observed between the two anticipated stigma scales,
but these scales still shared less than half of their variance with one
another (R ⫽ .64; R-squared ⫽ .41). In support of the convergent and
discriminant validity of endorsed and anticipated stigma scales rela-
tive to other scales in this inventory (Campbell & Fiske, 1959), the
average correlations observed among the three endorsed scales (.54)
and the correlation between the two anticipated scales (.64) both
exceeded the average correlations observed between endorsed and
anticipated stigma scales (.29).
Given that the EASI assesses beliefs that may portray individuals in
an unfavorable light (e.g., “I don’t feel comfortable around people
with mental health problems”), it is possible that this set of scales may
be affected by a general tendency to respond in a socially desirable
manner. Thus, we also examined the association between these scales
and a measure of socially desirable response style. As indicated in
Table 2, associations between these scales were in the modest range,
suggesting that responses on these scales are, at least to a small extent,
negatively related to a general tendency to respond in a more socially
desirable manner.
Prior research indicates that individuals with mental health prob-
lems endorse more concerns about stigma. Thus, evidence for dis-
criminative validity would be provided to the extent that individuals
with probable mental health problems report more stigma on the
EASI scales than individuals who do not meet criteria for mental
health problems. For the purpose of this analysis, individuals who met
criteria for probable PTSD, depression, or substance abuse (n ⫽ 139
for PTSD, n ⫽ 263 for depression, and n ⫽ 106 for substance abuse)
were compared with individuals who did not meet criteria for these
mental health conditions. As indicated in Table 3, mean differences
were observed on most EASI scales for those with and without these
probable mental health conditions, suggesting that individuals with
mental health problems endorsed more stigma than those who did not
report symptoms consistent with PTSD, depression, or alcohol abuse.
Part 4: Factor Structure
Part 4 was an examination of the factor structure of the EASI.
Confirmatory factor analyses were conducted to examine the pro-
posed five-factor structure underlying the five scales of the EASI, as
it compares with other plausible factor structures. Specifically, this
model was compared with: (a) a two-factor model that specified two
separate endorsed and anticipated stigma factors, (b) a one-factor
model that specified one large factor subsuming all stigma scales, (c)
Table 2
Correlations Among EASI Scales
Variable 1 2
1. Beliefs about mental illness — .55ⴱ
2. Beliefs about mental health treatment — .61ⴱ
3. Beliefs about treatment seeking
4. Concerns about stigma from loved ones
5. Concerns about stigma in the workplace
6. Social desirability
Note. ns ranged from 646 – 681.
ⴱ
p ⬍ .05.
109
a second-order factor structures that included two higher-level con-
structs corresponding to endorsed and anticipated stigma and five
first-order factors corresponding to the five proposed scales, and (d) a
second-order factor structure that included a single overriding second-
order stigma factor and five first-order factors corresponding to the
five proposed scales. We conducted analyses using MPlus Version
3.11 (Muthén & Muthén, 2004) and applied maximum likelihood
estimation.
The model that corresponded to the five proposed scales provided
better fit to the data than any of the alternative model structures that
were tested, as indicated in the results presented in Table 4. Although
the chi square statistics for all models were significant (p ⬍ .05), this
is common in larger samples and indices based on the noncentral chi
square (i.e., RMSEA and CFI) are considered more relevant to inter-
preting fit under these circumstances (Browne & Cudeck, 1993). The
RMSEA for the five-factor model demonstrated good fit (Browne &
Cudeck, 1993; Hu & Bentler, 1998; Steiger, 1990), and the Compar-
ative Fit Index (CFI; Bentler, 1990) approached the recommended
value of .90 (Byrne, 1994). Likewise, the Standardized Root Mean
Square Residual (SRMR) was well below the minimum recom-
mended values of .10 (Hu & Bentler, 1998) for the five-factor model.
In addition, all items proposed to load on each of the five factors had
critical ratios that exceeded 2.00 and all standardized factor loadings
for each of the five factors exceeded .40 (average of .64 for Beliefs
about Treatment, .66 for Beliefs about Treatment-Seeking, and .66 for
Beliefs about Mental Illness, .76 for Concern about Stigma from
Loved Ones, and .79 for Concerns about Stigma in the Workplace).
In contrast, fit indices for both the two-factor and one-factor models
were indicative of poor fit and chi square difference tests demon-
strated superior fit for the five-factor model relative to either the
two-factor or one-factor models. Fit was also weaker for the two
second-order factor structures that were tested. It is noteworthy,
however, that the second-order factor structure that specified two
higher-level factors corresponding to endorsed and anticipated stigma
demonstrated only slightly worse fit than the five-factor model, pro-
viding support for the broader distinction that has been drawn be-
tween endorsed and anticipated stigma. Further details regarding these
factor solutions are available from the first author.
Summary and Discussion
The goal of this study was to create a theoretically grounded and
psychometrically strong measure of stigma-related mental health be-
liefs that could be used with military and veteran populations. Evi-
dence for the content validity, internal consistency reliability, conver-
gent and discriminant validity, discriminative validity, and factor
3 4 5 6
.47ⴱ .51ⴱ .36ⴱ ⫺.13ⴱ
.49ⴱ .37ⴱ ⫺.25ⴱ
— .48ⴱ .38ⴱ ⫺.24ⴱ
— .64ⴱ ⫺.31ⴱ
— ⫺.25ⴱ
—
110 VOGT, DI LEONE, WANG, SAYER, PINELES, AND LITZ

Table 3
Mean Differences on EASI Scales for Individuals With and Without Mental Health Problems

Above threshold Below threshold

Study Variables Mean SD n Mean SD n df t r

Probable PTSD
Beliefs about mental illness 17.46 5.63 136 18.18 5.63 513 647 1.32 .05
Beliefs about mental health treatment 21.60 6.36 135 18.74 5.04 515 648 ⫺5.54ⴱ .21
Beliefs about treatment seeking 22.51 7.42 135 20.83 6.66 519 652 ⫺2.55ⴱ .10
Concerns about stigma from loved ones 22.23 8.12 133 17.42 7.08 511 642 ⫺6.78ⴱ .26
Concerns about stigma in workplace 27.20 7.66 138 22.75 7.28 511 647 ⫺6.30ⴱ .24
Probable depression
Beliefs about mental illness 18.40 5.76 253 17.89 5.54 403 654 ⫺1.11 .04
Beliefs about mental health treatment 20.48 5.83 252 18.67 5.03 404 654 ⫺4.21ⴱ .16
Beliefs about treatment seeking 22.38 7.31 253 20.33 6.48 407 658 ⫺3.76ⴱ .15
Concerns about stigma from loved ones 20.93 8.08 250 16.93 6.79 401 649 ⫺6.78ⴱ .26
Concerns about stigma in workplace 26.09 7.72 253 22.22 7.04 404 655 ⫺6.60ⴱ .25
Probable alcohol abuse
Beliefs about mental illness 17.75 5.63 103 18.14 5.64 553 654 .64 .03
Beliefs about mental health treatment 20.13 5.63 106 19.24 5.41 548 652 ⫺1.55 .06
Beliefs about treatment seeking 22.65 6.98 104 20.87 6.81 556 658 ⫺2.45ⴱ .10
Concerns about stigma from loved ones 19.89 8.05 102 18.26 7.42 547 647 ⫺2.01ⴱ .08
Concerns about stigma in workplace 25.39 7.43 105 23.41 7.54 551 654 ⫺2.48ⴱ .10
ⴱ
p ⬍ .05.

structure of the EASI was provided. The full inventory takes less than
10 minutes to complete. As such, it offers an efficient tool for
assessing dimensions of both endorsed and anticipated mental health
stigma that are likely to have implications for mental health treatment.
Findings based on the EASI can be applied to inform public health
interventions targeted at reducing mental health stigma among mili-
tary and veteran populations. Specifically, this scale can be used to
pinpoint specific components of stigma that require attention in public
health campaigns. For example, if negative beliefs about treatment
seeking are found to be a key barrier to care, this would suggest the
need for interventions targeted at encouraging and normalizing help-
seeking. Alternatively, the findings that negative beliefs about mental
illness or mental health treatment are particularly common would
underscore the importance of efforts aimed at correcting mispercep-
tions about people with mental illness and educating military person-
nel and veterans about the benefits of mental health treatment. Scales
from the EASI may also be applied to identify subpopulations that
would benefit most from public health interventions. For example, if
men were identified as more likely to hold negative beliefs about
mental health treatment than women, it would suggest a greater need
for interventions targeted to male rather than female veterans. More-
over, the EASI assesses anticipated stigma from loved ones, a con-
struct that has received less attention in the military and veteran
literature.
Although initial psychometric support for of the EASI is encour-
aging, additional research is needed to further explore its psychomet-
ric properties. For example, evidence is needed for the test–retest
reliability of this suite of scales, and it will be important to validate the
psychometric characteristics of the EASI in other military and veteran
samples, including current servicemembers and other veteran cohorts
(e.g., Vietnam veterans). In addition, though this measure was spe-
cifically developed for use in military and veteran populations, future
research should examine its generalizability to other groups with high
base-rate mental health problems. Future studies should also explore
how this measure relates to other measures that address related aspects
of mental health stigma, such as the Perceived Stigma and Barriers to
Care for Psychological Problems measure (Britt, 2000). It will be
especially important to evaluate how the endorsed stigma scales
assessed in the EASI relate to measures of other components of the
self-stigmatization process. For example, an important research ques-
tion pertains to the impact of endorsed stigma on the self-esteem of
individuals who experience mental health problems, as internalized
stigma is likely to be a key mechanism through which negative beliefs
about mental illness and mental health treatment have their impact on

Table 4
Goodness-of-Fit Indices for Five-, Two-, and One-Factor Models

Model fit Comparison

Model ␹ 2
df RMSEA CFI SRMR Models ␹diff
2
dfdiff
ⴱ
1. Five-factor model 2455.32 730 .06 .89 .05
2. Two-factor first-order model 5289.65ⴱ 739 .09 .71 .08 1 vs. 2 2834.33ⴱ 9
3. One-factor first-order model 7517.34ⴱ 740 .12 .57 .10 1 vs. 3 5062.02ⴱ 10
4. Two-factor second-order model 2484.10ⴱ 734 .06 .89 .05 1 vs. 4 28.68ⴱ 4
5. One-factor second-order model 2606.04ⴱ 735 .06 .88 .06 1 vs. 5 150.72ⴱ 5
Note. N ⫽ 698.
ⴱ
p ⬍ .05.
 ENDORSED AND ANTICIPATED STIGMA INVENTORY
treatment seeking. It is also important to recognize that responses to
EASI scales are modestly associated with concerns about social
desirability. Thus, researchers who use this inventory of scales in
future studies may wish to consider controlling for social desirability
as appropriate.
Finally, it is important to recognize that not all mental health beliefs
addressed in the EASI necessarily represent beliefs that are based on
biased or inaccurate appraisals. For example, the concern that there
may be negative career consequences if supervisors or coworkers
know about mental health problems is often a valid concern for
military personnel, given that commanding officers may use medical
records to inform decisions about whether a servicemember is fit to
perform specific job responsibilities (Porter & Johnson, 1994; Rosen
& Corcoran, 1978). Likewise, some personal beliefs about mental
illness and mental health treatment may be valid. For example, con-
cerns about the negative side effects of medication for mental health
problems may be quite well-founded in some cases.
In conclusion, the EASI is a new inventory that assesses mental
health beliefs that may be particularly salient for military and veteran
populations. It is our hope that the availability of these scales will spur
further research on the role of mental health stigma in servicemem-
bers’ and veterans’ willingness to seek mental health treatment, and
inform interventions aimed at addressing aspects of mental health
stigma that serve as barriers to care.
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 ENDORSED AND ANTICIPATED STIGMA INVENTORY 113

Appendix
Items From the Endorsed and Anticipated Stigma Inventory (EASI)

Beliefs About Mental Illness 4. Most mental health problems can be dealt with without
seeking professional help.
1. People with mental health problems cannot be counted on.
5. Seeing a mental health provider would make me feel weak.
2. People with mental health problems often use their health
problems as an excuse. 6. I would think less of myself if I were to seek mental
health treatment.
3. Most people with mental health problems are just faking
their symptoms. 7. If I were to seek mental health treatment, I would feel
stupid for not being able to fix the problem on my own.
4. I don’t feel comfortable around people with mental health
problems. 8. I wouldn’t want to share personal information with a
mental health provider.
5. It would be difficult to have a normal relationship with
someone with mental health problems.
Concerns About Stigma From Loved Ones
6. Most people with mental health problems are violent or If I had a mental health problem and friends and family knew
dangerous. about it, they would . . .

7. People with mental health problems require too much atten- 1. . . . think less of me.
tion.
2. . . . see me as weak.
8. People with mental health problems can’t take care of
themselves. 3. . . . feel uncomfortable around me.

Beliefs About Mental Health Treatment 4. . . . not want to be around me.

1. Medications for mental health problems are ineffective. 5. . . . think I was faking.

2. Mental health treatment just makes things worse. 6. . . . Be afraid that I might be violent or dangerous.

3. Mental health providers don’t really care about their patients. 7. . . . think that I could not be trusted.

4. Mental health treatment generally does not work. 8. . . . avoid talking to me.

5. Therapy/counseling does not really help for mental health Concerns About Stigma in the Workplace
problems.
If I had a mental health problem and people at work knew about it . . .
6. People who seek mental health treatment are often re-
quired to undergo treatments they don’t want. 1. My coworkers would think I am not capable of doing my job.

7. Medications for mental health problems have too many 2. People at work would not want to be around me.
negative side effects.
3. My career/job options would be limited.
8. Mental health providers often make inaccurate assump-
tions about patients based on their group membership 4. Coworkers would feel uncomfortable around me.
(e.g., race, sex, etc.).
5. A Supervisor might give me less desirable work.
Beliefs About Treatment Seeking
6. A Supervisor might treat me unfairly.
1. A problem would have to be really bad for me to be
7. People at work would think I was faking.
willing to seek mental health care.
8. Co-workers would avoid talking to me.
2. I would feel uncomfortable talking about my problems
with a mental health provider.
Received August 6, 2012
3. If I had a mental health problem, I would prefer to deal Revision received January 28, 2013
with it myself rather than to seek treatment. Accepted January 28, 2013 䡲