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Community conversation: Addressing mental

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ARTICLE in SOCIAL PSYCHIATRY · AUGUST 2009

Impact Factor: 2.54 · DOI: 10.1007/s00127-009-0095-4 · Source: PubMed

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Soc Psychiat Epidemiol
DOI 10.1007/s00127-009-0095-4
ORIGINAL PAPER
Community conversation: addressing mental health stigma
with ethnic minority communities
Lee Knifton Æ Mhairi Gervais Æ Karen Newbigging Æ
Nuzhat Mirza Æ Neil Quinn Æ Neil Wilson Æ
Evette Hunkins-Hutchison
Received: 22 December 2008 / Accepted: 2 July 2009

Springer-Verlag 2009
Abstract
Introduction Stigma associated with mental health prob-
lems is a significant public health issue. Patterns of stigma
and discrimination vary between and within communities
and are related to conceptualisations of, and beliefs about,
mental health. Population approaches to addressing stigma
rarely consider diverse cultural understandings of mental
health.
Methods 257 members of the major black and minority
ethnic communities in Scotland participated in 26 mental
health awareness workshops that were designed and
delivered by community organisations. Questionnaires
measuring knowledge, attitudes and behavioural intent
were completed before and after the intervention.
Results Community led approaches that acknowledge
cultural constructs of mental health were received posi-
tively by community groups. The study found significant
reported stigma in relation to public protection, marriage,
shame and contribution, but also high levels of recovery
optimism. The workshops resulted in significant positive
L. Knifton (&)
N. Quinn
Glasgow School of Social Work, A Joint School of Universities
of Glasgow and Strathclyde, Glasgow, Scotland, UK
e-mail: Leeknifton@gmail.com
M. Gervais
Department of Psychological Medicine, University of Glasgow,
Glasgow, Scotland, UK
K. Newbigging
E. Hunkins-Hutchison
Centre for Ethnicity and Health, University of Central
Lancashire, Lancashire, UK
N. Mirza
N. Wilson
NHS Greater Glasgow and Clyde,
Glasgow, Scotland, UK
change in relation to knowledge, attitudes and behavioural
intent amongst participants, with most aspects of stigma
showing significant improvement, with the exception of
dangerousness.
Discussion The paper argues community approaches to
tackling stigma are more valuable than top-down public
education and could form the basis of national initiatives.
Refinements to the evaluation framework are considered.
Keywords Mental
Stigma
Discrimination

Ethnicminority
Introduction
Mental health problems are a global health issue with the
associated stigma and discrimination resulting in social
exclusion and inhibiting help-seeking and recovery. Stigma
involves a combination of inaccurate knowledge and stig-
matising attitudes, leading to individuals being excluded
and discriminated against [1, 4, 29]. Different mental health
problems attract particular forms of stigma including dan-
gerousness, social distance, blame and recovery pessimism
[5, 6]. National programmes addressing stigma rarely con-
sider diverse cultural understandings of mental health,
particularly from black and ethnic minority (BME) com-
munities, who may have different explanatory frameworks
and who experience structural discrimination and multiple
forms of stigma, including racism and disempowerment [7].
This study explores stigma with BME communities in
Scotland that have migrated from India, Pakistan and
China, encompassing a range of cultures and religions.
International studies of the three major BME communities
highlight significant levels of stigma, shaped by factors
including community and family structure, beliefs about
123

mental health problems and experiences of racism and
migration. Direct comparisons between studies are not
useful because of the heterogeneity of the communities in
terms of religious and cultural differences and the research
methods that have been used. However, some core themes
do emerge.
In Pakistan, behaviour by a person with a mental health
problem that is embarrassing, or draws attention towards
the individual or family, may be considered unacceptable.
People with mental health problems may have limited
social opportunities and experience discrimination in areas
such as education, employment and healthcare [12]. Family
reputation and is a consistent issue in studies of Asian
minority communities; the implication being that mental
health problems can compromise ability to fulfill family
obligations and inhibits disclosure [30]. In a UK study of
Pakistani minority communities [24], participants indicated
a general willingness to interact at a superficial level with
someone experiencing mental health problems but none
would consider marriage. Within minority Chinese com-
munities, numerous studies suggest shame and guilt are
also major dimensions of stigma, with families of people
with a mental health problem fearful of being exposed to
criticism, disgrace and losing face [13, 31]. Blackwell [2]
reports that people often hide mental health problems and
avoid treatment. Service users expressed a lack of sup-
portive relationships and blame from some family mem-
bers [14]. Dangerousness also emerges as an important
source of stigma in a study drawing on the Chinese com-
munity in Manchester [28].
These studies suggest that shame and other stigmatising
attitudes may be prevalent within these communities
leading to significant discrimination. The experience of
isolation and social exclusion are also evident at the level
of individual, family and society, compounded by the
discrimination and racism associated with membership of
an ethnic minority community.
Community led studies using focus group methods in
Scotland with Pakistani, Indian and Chinese communities
found similar stigma towards mental health problems with
areas including shame and concealment; perceived causes
including punishment from God, black-magic, spirits or
jinn; recovery pessimism and profound concerns about
marriage prospects often linked to contagion and impact
upon educational achievements [8]. Patterns of belief var-
ied across communities and reported stigma was lower
with younger and more affluent participants.
This emphasis upon shame may be attributable to differ-
ent explanatory frameworks about mental health problems,
particularly different holistic beliefs about causality that do
not correlate with the medical model. Cultural differences in
beliefs have been identified amongst British Asian, Western
European and Pakistani communities [23]. Other UK studies
123
Soc Psychiat Epidemiol
have found differences in perceptions in relation to schizo-
phrenia across different ethnic populations [19]. Social
explanations of mental health problems are a common theme
across studies, including the impact of migration [22, 25, 26].
Within South Asian communities certain cultural beliefs
about causation can lead directly to shame, such as mental
health problems as punishment for wrong-doings [12], as
God’s will [9, 10], and as black-magic, jinn or possession by
spirits [11, 24]. There is a diverse range of explanations of
mental health and patterns of stigma between communities,
which are rarely homogenous, and there are significant
variations according to faith, religion, gender, generation
and age, thus creating a mosaic of meaning [16].
What works?
The evidence of what works in addressing stigma with BME
communities is limited. Anti-stigma activities are often one
aspect of mental health projects with BME communities
and are rarely evaluated systematically [21]. National anti-
stigma programmes are often culturally inappropriate [26]
including in Scotland where the national anti-stigma cam-
paign has failed to use appropriate media channels, multi-
racial images and role models, and clear or translated lan-
guage on materials [8]. Participating communities talked
positively about community interventions and discussion
groups to address stigma, and targeted work in community
venues and with family members, clinicians and media used
by BME communities shows some promise [17, 27, 30].
These findings suggest the value of community devel-
opment approaches that engage with people that are
designed and delivered by community organisations and
work within cultural understandings of mental health.
Interventions should take account of the significant varia-
tion within and between communities, including gender,
generational, faith and cultural differences.
This study focuses upon community conversation
workshops and aims to:
• Evaluate the acceptability and practicability of a
community development workshop programme.
• Explore attitudes towards mental health problems
amongst the three target communities in the study.
• Assess the impact of workshops upon participants.
• Consider the value of different evaluation approaches
with target communities.
Method
The intervention ‘community conversation’ explored men-
tal health and stigma in safe, supportive workshops of
90 min. Health and BME community organisations
Soc Psychiat Epidemiol
designed and delivered the workshops to ensure cultural
sensitivity in terms of language, process and content. The
workshops aimed to provide information and facilitate
discussion around mental health and stigma. Topics
addressed in the workshop included: frequency of mental
health problems; range of mental health problems; under-
standing stigma including fear, social contribution, isola-
tion, blame and recovery; what we can do to address stigma.
Participants were members of existing BME community
groups who had volunteered to attend a workshop, with
groups being divided by gender or generation, where it was
felt this was important to ensure the success of the dis-
cussion. Participants from the Indian communities were
selected from community centres. The Pakistani commu-
nity was drawn from the local development agency and
community and faith groups. The Chinese community
workshop ran with participants from a healthy living cen-
tre. By working through established groups we were able to
ensure a supportive environment if sensitive issues were
raised, and build sustainability into the intervention if it
proved effective.
Evaluation design
The evaluation process, designed in partnership with BME
community organisations, aimed to measure changes in the
knowledge, attitudes and behavioural intent of the partici-
pants and workshop acceptability. One pre- and one post-
workshop questionnaire was used for each participant,
translated into Chinese, Urdu and Hindi as required, and
group workers were also available.
The questionnaire used similar wording to the national
Scottish survey of public attitudes to mental health [3],
allowing comparisons with the national survey which only
achieved a response from 2% of the BME communities.
The first 11 questions on both the pre- and post-workshop
questionnaires are identical. It was decided to use words to
describe the extent of agreement as well as a corresponding
numerical scale for clarity. Most community representa-
tives thought that their groups would find the worded scale
easier to understand and that it was more likely to elicit an
accurate response. A five-point scale was used instead of a
seven-point scale for ease of understanding and translation.
Although the seven-point scale may have picked up on
more subtle changes in participants’ attitudes and opinions,
this might have been confounded by subtle differences in
the translation of words like ‘‘slightly’’ and ‘‘strongly’’.
Minor alterations were made to the questions, e.g., Ques-
tion 10: ‘‘Anyone can experience a mental health problem’’
was reworded from ‘‘Anyone can suffer from a mental
health problem’’ to avoid negative language. Questions
1–5, and 9–11 were adapted from the attitude section of the
Scottish survey. Questions 6, 7, and 8 were adapted from
the vignettes section of the attitudes survey, which look at
social distance (Table 1).
Pre-questionnaires identified age, gender, religion and
ethnicity for cross-comparison of the questions, replaced in
post-group questionnaires by open questions on workshop
acceptability and changes in their knowledge, beliefs and
behavioural intent as a result of the workshop, and were
open-ended in order to elicit unexpected responses (Fig. 1).
Data were analysed using the Statistical Package for
Social Scientists. Qualitative data were systematically
coded in order to enable the identification of key themes
and issues [15], within a framework of knowledge, atti-
tudes and behaviour towards mental health.
Results
Demographic background of participants
Across the three communities, 26 workshops were deliv-
ered to 257 participants over a 9-week period, and 246
(96%) participants completed the evaluations. Workshop
numbers ranged from 6 to 20 with an average of 9
attendees. Table 2 outlines demographic information
gathered from participants. The majority of participants
were female (180, 73%). In terms of age; the Chinese
community groups displayed a normal distribution, the
Indian community was highly skewed towards the older
age group and the Pakistani group was skewed towards the
younger age groups. Most participants considered them-
selves to be either Chinese (n = 95, 40.7%), Indian
(n = 63, 27%) or Pakistani (n = 50, 21.5%). Islam was
reported as the most common religion (n = 69, 28.8%),
Table 1 Attitudinal questions
1. Mental health problems are very common.
2. The public should be better protected from people with mental
health problems.
3. I would find it hard to talk to someone with mental health problems.
4. People with mental health problems should have the same rights as
anyone else.
5. People with mental health problems are to blame for their own
condition.
6. I would not be willing to work with someone with a mental health
problem.
7. I would be happy for someone with a mental health problem to
marry into my family.
8. People with mental health problems cannot contribute to society.
9. The majority of people with mental health problems recover.
10. Anyone can experience a mental health problem.
11. If I had a mental health problem, I wouldn’t want to tell anyone
about it.
123
 Soc Psychiat Epidemiol

Fig. 1 Baseline attitudes of Percentage of Baseline Stigma by Question

participants 90
Non-stigmatizing responses
Stigmatizing responses
80
No Opinion

70

60

50

40

30

20

10

0
Common Protected Talk RightS Blame Work Marry Contribute Recover Anyone Not Tell
Question

Table 2 Demographic information of participants

Community of No. of No. of No. of Missing data Total no. of Most common
each group workshops males females (no gender identified) participants age group

Chinese community 9 26 (25%) 69 (67%) 8 (8%) 103 (42%) 45–54

Indian community 9 21 (28%) 51 (68%) 3 (4%) 75 (30%) 65–74
Pakistani community 8 8 (12%) 60 (88%) 0 68 (28%) 35–44
Total 26 55 (22%) 180 (73%) 11 (5%) 246

and all major religions are represented apart from Judaism,
as well as those who chose ‘‘no answer’’ (n = 57, 23.8%).
Baseline attitudes of participants
At baseline over 50% of participants expressed stigmatiz-
ing responses in relations to public protection, marrying or
talking to someone with a mental health problem, and
contribution to communities. There was a more even bal-
ance of positive and negative responses towards equal
rights, ability to work and willingness to disclose. There
was strong agreement that problems are common, people
are not to blame, can happen to anyone and people recover,
each of which had over 50% non-stigmatizing responses.
Participant baseline scores are more negative compared
to the 2006 public attitudes survey in Scotland for: talking
about mental health problems; public protection; having
equal rights; being to blame; that anyone is at risk. Will-
ingness for someone marry into family was very low,
compared to the Scottish Public Attitudes Survey [3],
which varied from 26% for schizophrenia to 53% for stress.
Rates were similar between the two studies for not dis-
closing a mental health problem, and there were consid-
erably higher levels of recovery optimism.
Workshop impact
Table 3 describes the mean stigma score calculated for the
entire sample before and after the workshops. This differ-
ence was found to be statistically significant at P = 0.000
(Z = -5.423, df = 1) meaning that there was less stigma
reported after completion of the workshops.
In order to look at the impact of the workshop on par-
ticipants’ responses to each question, the data were recoded
into three categories. The first is ‘no change’ when the
participant chose the same answer both pre- and post-
workshop. ‘Positive change’ is when the participant
changed their response to show less stigma. e.g., For
questions 1, 4, 7, 9 and 10 the workshop aimed to increase
agreement with the statement, the other questions aimed to
increase disagreement with stigmatising statements. ‘Neg-
ative change’ is when the participants indicated more
stigma in their responses to the post-workshop question-
naire. No change is the most frequent outcome with the
exception of Q2 (protection), Q9 (recovery) and Q11
(disclosure).
Table 4 shows that responses to 6 of the 11 questions
improved significantly after the workshops, 4 questions
showed no significant change, and responses to 1 question

123
Soc Psychiat Epidemiol
Table 3 Comparison of participant responses with Scottish Public attitudes survey 2006 (%)
Talk about Public
MHPs protection
Public attitudes 2006 31 32
Study sample 17 55
Table 4 Wilcoxon Signed Rank test of overall differences in stigma
before and after workshop
N Mean SD Min Max Z Asymp sig.
Stigma score
Pre 243 2.82 0.53 1.09 4.27 -5.423
Post 232 2.60 0.64 1.00 4.00
concerning ‘work’ worsened. Change did not depend upon
a questions’ initial baseline score.
Demographic effects in terms of variability in the
impact of the workshops upon participants were analysed
using cross-tabulations for each of the 11 questions in four
domains: age (re-categorised into 16–44, 45–64 and 65?);
gender, community and religion (due to the small numbers
of Christians in each category, Christian CoS, Christian RC
and Christian other were combined in one category and
compared to Buddhism, Hinduism, Islam, Sikh and those
who opted not to disclose their religion, referred to as ‘no
answer’). Those who had not changed their minds were
excluded from this analysis. The results in Table 5 show
very similar patterns of impact across the participants with
no variance in 35 of the 44 potential differences. The 9
areas of variability were distributed across 6 of the 11
questions and across the 4 demographic categories,
although the low counts for religion suggest that this
dimension has no effect at all. The overall picture is one of
low variability in impact (Table 6).
Qualitative feedback
Responses were content-analysed to describe the frequency
of the main themes identified. 71% of participants
responded to the question ‘What did you learn?’ and 80%
of participants of those who responded felt they had
learned something, 22% said they learned a lot and only
14% claimed not to have learned anything. 30% identified
one of the key learning points of the workshop, 11% were
able to provide specific statistics or information, particu-
larly that mental health problems could be mild as well as
severe. 8% learned about the benefits of talking and
seeking help. 59% of participants responded to the ques-
tion, ‘Did your beliefs change?’ and 78% claimed to have
changed their beliefs, with only 16% stating that the
Equal Blame Anyone can Marry into Disclose People
rights develop MHP family MHP recover
85 4 97 26–53 40 46
50 20 58 15 40 67
workshop had not. The most common change identified
was not to insult or discriminate against people with mental
health problems. 40% of participants responded to the
(two-tailed) question ‘What would you do differently in future?’ and
91% identified a change that they would make in the future
as a result of the workshop with only 7% of participants
0.000
stating that they would not do anything differently. The
most common change identified was to seek help if it was
needed, some of whom stated that they were going to seek
help for a current problem. 46% stated an intention to be
more tolerant and supportive of people with mental health
problems.
Discussion
The findings suggest that community conversation work-
shops effectively engaged participants, and resulted in
reductions in reported stigma. This discussion will explore
the validity and implications of these findings in the con-
text of a mosaic of complex inter-linked factors including
ethnicity and culture, and conceptualisations of mental
health.
How acceptable and practicable was the approach?
The involvement of a wide range of community organisa-
tions in the development and delivery of the programme
resulted in significant uptake and supports community
development approaches which value community knowl-
edge and cultural constructs of mental health. Across
communities, greater uptake by women and older people
may be because workshops took place in the daytime
which precluded people at work or education. To reach a
wider cross-section of the population, community organi-
zations should deliver workshops in schools and work-
places, which has been effective in other studies [20]. A
bigger challenge is to engage with people who are mar-
ginalised from community structures and more vulnerable
to developing mental health problems.
As workshops evolve we suggest an iterative process of
development involving community development workers,
based on feedback and the research findings. A suggested
development would be the inclusion of narratives delivered
by service users from BME communities, which has been
123
 Soc Psychiat Epidemiol

Table 5 v2 test of changes in response to each question

Question (N) Missing data No change Positive change Negative change Chi-squared Significance

1. Common (224) 22 127 (56.7%) 78 (34.8%) 19 (8.5%) 35.89 (1) 0.000 positive
2. Protection (217) 29 71 (32.7%) 69 (31.8%) 77 (35.5%) 0.44 (1) 0.508
3. Talk to (222) 24 100 (45%) 85 (38.3%) 37 (16.7%) 18.89 (1) 0.000 positive
4. Rights (219) 27 127 (58%) 52 (23.7) 40 (18.3%) 1.57 (1) 0.211
5. Blame (222) 24 132 (59.5%) 67 (30.2%) 23 (10.4%) 21.51 (1) 0.000 positive
6. Work (220) 26 96 (43.6%) 51 (23.2%) 73 (33.2%) 3.90 (1) 0.048 negative
7. Marry (224) 22 126 (56.3%) 66 (29.5%) 32 (14.3%) 11.80 (1) 0.001 positive
8. Contribute (217) 29 104 (47.9%) 59 (27.2%) 54 (24.9%) 0.221 (1) 0.638
9. Recover (221) 25 88 (39.8%) 110 (49.8%) 23 (10.4%) 56.91(1) 0.000 positive
10. Anyone (221) 25 121 (54.8%) 48 (21.7%) 52(23.5%) 0.16 (1) 0.689
11. Disclose (220) 26 82 (37.3%) 89 (40.5%) 49 (22.3%) 11.59 (1) 0.001 positive

Table 6 Differences in
workshop impact between and
within communities
Question Differential impact
1. Common Younger age changed more positively N = 97, v2(2) = 6.983,
P = 0.030
Chinese community changed more positively N = 97, v2(2) = 7.437,
P = 0.024 (caution, violated by low expected count in one cell)
2. Protection Chinese community showed less positive change N = 146,
v2(2) = 30.608, P = 0.000
7. Marry Females showed more positive change N = 95, v2 (1) = 3.929,
P = 0.042
8. Contribute Chinese community showed less positive change N = 113,
v2(2) = 6.296, P = 0.043 Males showed more positive change
N = 140, v2(1) = 11.988, P = 0.001
9. Recovery Pakistani community showed less positive change N = 133,
v2(2) = 11.813, P = 0.003
Islamic participants showed less positive change N = 130,
v2 = 15.656 (5), P = 0.008 (violated by low expected counts in five
cells therefore interpreted with caution)
11. Disclose Younger age responded less positively N = 134, v2(2) = 7.897,
P = 0.019

shown to be effective in other studies [18] but challenging
given the limited involvement of the service user move-
ment with BME communities in Scotland [8].
What do the baseline results tell us?
At baseline there were significant levels of stigma across
the three communities. Areas that attracted the most stig-
matizing responses included: dangerousness (public pro-
tection); social distance (marrying and talking to someone
with a mental health problem); capability (social contri-
bution and work); secrecy and shame (tell anyone) and
equal rights. These results are broadly in line with the
findings from qualitative studies outlined in the literature
review, which highlighted how mental health problems
may attract shame within families and communities [30].
However, other findings indicate less stigma with low
levels of blame and a view that mental health problems are
common and can develop in anyone. This suggests that
some of the traditional beliefs about causation identified in
the literature such as blame for sins and mental health
problems as a punishment were not strongly held amongst
participants [8, 12]. A potentially important finding was
high levels of recovery optimism amongst participants,
contradicting recent Scottish studies [8] and supporting the
use of positive recovery based messages to challenge
negative views about marriage prospects, social contact,
contribution, and shame.
The baseline scores within the study are valuable in
understanding change within the groups for this interven-
tion. However, we must be cautious when making com-
parisons against population level attitudinal studies as there
is evidence that some members of the community may
assume that questionnaires refer to more severe mental
health problems, which attract higher levels of stigma [6].
In addition, questionnaires were administered in a safe

123
Soc Psychiat Epidemiol
setting which may have generated more honest responses,
and questionnaires were translated and subtle differences in
language and phrasing may skew results. There were no
refusals to participate and the sample was therefore likely
to be less self-selecting than the Scottish Public Attitudes
sample. And finally, there is also evidence that BME
communities have not been reached effectively by national
anti-stigma messages so participants may have been less
influenced either by the campaign or even to report idea-
lised responses. Community research might be a valuable
way of exploring the significance of baseline findings that
were particularly negative or positive.
Impact of workshops
Overall positive changes in attitudes towards mental health
problems link to wider themes and concerns identified in
the literature. The increased recognition that mental health
problems are common, alongside a willingness to tell
someone, is arguably a reduction in secrecy and shame.
This is accompanied by a reduction in desire for social
distance, with an increased willingness to talk to someone
and allow someone to marry into the family, an area of
particular concern in the literature [24, 30]. The reduction
in blame and increased recovery optimism suggests that a
community conversation model has the potential to engage
communities and promote a culture of greater openness and
acceptance towards mental health issues. Whilst further
research is required, it indicates that community develop-
ment approaches which construct shared meanings and
understandings may be more valuable than top-down
public education approaches.
Attitudes worsened in relation to the impact of returning
to work. This was the only area that worsened. It may be
attributable to the question using a double negative and
being less clear to some participants who were less confi-
dent in their use of English language. However, it might be
that the participants became more aware of workplace
stigma. There was no significant improvement in percep-
tions of dangerousness or unpredictability. This may be
because this was assessed by a question on public protec-
tion, which assumes protection is the responsibility of the
state, whereas amongst some BME communities, there
may be a greater perceived role for families. In addition,
neither of these issues were a major feature of the work-
shop and future developments should address this. Overall
the questions that had higher levels of stigma did not
improve any more than those that had more positive initial
scores, suggesting that there is not a ‘ceiling effect’ in this
study.
The workshops had a similar impact upon participant
attitudes according to age, gender and ethnicity. However,
they do indicate enough variation between and within
communities to indicate that intervention models need to
be developed by and not for communities, and tailored for
variance within communities. Moreover, there is no reason
to suggest that the importance of community development
and constructivist approaches to addressing stigma only
applies to BME communities.
What are the major strengths and limitations
of the evaluation approach?
The use of modified and translated questionnaires makes a
valuable contribution to our understanding of patterns of
stigma within the BME communities, but findings must be
interpreted very cautiously. Scales and measures are useful
in getting a sense of the elements of stigma that are
affected positively and negatively by the intervention, and
this specificity can often be missed in qualitative research.
Potential limitations include subtle meanings of questions
being altered in translation, risk that questions assume a
shared view of mental health problems that is western, and
intra-group diversity such as generational differences may
not be fully identified.
Further issues limit the degree to which we can gener-
alise findings, including the lack of specificity in defining
mental health problems, the short-term nature of the study,
and the fact it assessed behavioural intent rather than actual
behaviour change. Whilst the sample used was not repre-
sentative in terms of gender and age, it was accessed
through community organisations and therefore not self-
selecting. We can therefore be reasonably confident that we
engaged a spectrum of views.
Future evaluations of impact would benefit from trian-
gulating these techniques with qualitative research. This
would provide richness and allow us to contextualize and
understand the meaning behind numerical data and reflect
the complexity of perceptions that exist. This approach
would also allow us to capture unexpected dimensions of
stigma and behavioural intent in an area that has a lot of
uncertainty. Issues of literacy in some community groups
suggest that interviews and focus groups would be more
valuable than written questionnaires.
Conclusions
Our findings indicate that community development work-
shops involving dialogue and engagement, might offer
more promise than national campaigns alone in reducing
the significant levels of stigma that exist within commu-
nities. Further research is needed to explore how they can
be integrated into existing population-level approaches.
However, they should only form one aspect of the overall
approach to addressing stigma with BME communities,
123

which should involve addressing structural discrimination,
racism, and wider barriers to inclusion. Whilst positive
effects occurred regardless of baseline levels of stigma, and
across communities, age, gender and religion, longer-term
follow-up and richer qualitative data would be valuable in
understanding the strength of this impact and the areas that
proved resistant to change such as dangerousness.
Acknowledgments The authors would like to acknowledge a broad
community of practice involved in this programme, including Chinese
Healthy Living Centre, Chinese Community Development Partner-
ship, STEPS Primary Care Team, Glasgow Association for Mental
Health, Mental Health Foundation, Shante Bhavan, Mel Milap, Pol-
lockshields Development Agency, Youth Counselling Services
Agency, NHS Greater Glasgow And Clyde. Particular acknowl-
edgements are due to Pratima Pershad for community development
support, and the staff and volunteers of CHLC for time spent devel-
oping the workshop template.
References
1. Berzins KM, Petch A, Atkinson J (2003) Prevalence and expe-
rience of harassment of people with mental health problems
living in the community. Br J Psychiatry 183:526–533
2. Blackwell MJ (1997) Psychiatrists and Chinese mental health in
Chinese mental health issues in Britain. Chinese Mental Health
Association/Mental Health Foundation. http://www.cmha.org.uk
3. Braunholtz S, Davidson S, Myant K, O’Connor R (2006) Well?
What do you think? The third national Scottish survey of public
attitudes to mental health, mental wellbeing and mental health
problems. Scottish Government, Edinburgh
4. Brown J, Hanlon P, Webster D, Turok I, Arnott J, MacDonald E
(2007) Turning the Tap Off! incapacity benefit in Glasgow and
Scotland—trends over the past five Years. Paper 6 in the Glasgow
Centre for Population Health Briefing Papers—Findings series.
http://www.gcph.co.uk
5. Corrigan PW, Penn DL (1999) Lessons from social psychology
on discrediting psychiatric stigma. Am Psychol 54(9):765–776
6. Crisp A, Gelder M, Rix S, Meltzer H, Rowlands O (2000) Stig-
matisation of people with mental illnesses. Br J Psychiatry 177:4–7
7. Gary FA (2005) Stigma: Barrier to mental health care among
ethnic minorities. Issues Ment Health Nurs 26(10):979–999
8. Glasgow Anti-Stigma Partnership (2006) Mosaics of meaning:
exploring stigma and discrimination towards mental health
problems with black and minority ethnic communities in Glas-
gow. http://www.healthscotland.com
9. Hatfield B, Mohammad H, Ahim Z, Tanweer H (1996) Mental
health and the Asian communities: a local survey. Br J Soc Work
26(3):315–336
10. Hussain A (2006) Islamic beliefs and mental health. http://
www.mentalhealth.org.uk/conferences/shift/Islam_mental_health.
pdf
11. Joel D, Sathyaseelan M, Jayakaran R, Vijayakumar C, Muthu-
rathnam S, Jacob KS (2003) Explanatory models of psychosis
among community health workers in South India. Acta Psychiatr
Scand 108(1):66–69
12. Karim S, Saeed K, Rana MH, Mubbashar MH, Jenkins R (2004)
Pakistan mental health country profile. Int Rev Psychiatr 16(1–
2):83–92
123
Soc Psychiat Epidemiol
13. Lee S, Lee M, Chiu M, Kleinman A (2005) Experience of social
stigma by people with schizophrenia in Hong Kong. Br J Psy-
chiatry 186(15):3–157
14. Li PL, Logan S, Yee L, Ng S (1999) Barriers to meeting the
mental health needs of the Chinese community. J Publ Health
Med 21(1):74–80
15. Miles MB, Huberman AM (1994) Qualitative data analysis: an
expanded source book, 2nd edn. Sage, Beverly Hills
16. Patel K (2005) The complex mosaic. Inaugural Professorial
Lecture. 12 May 2005. The Centre for Ethnicity and Health,
UCLAN
17. Phillips MR, Pearson V, Li F, Xu M, Yang L (2002) Stigma and
expressed emotion: a study of people with schizophrenia and their
family members in China. Br J Psychiatry 181:488–493
18. Pinfold V, Thornicroft G, Huxley P, Farmer P (2005) Active
ingredients in anti-stigma programmes in mental health. Int Rev
Psychiatry 17(2):123–131
19. Pote HL, Orrell MW (2002) Perceptions of schizophrenia in
multi-cultural Britain. Ethn Health 7(1):7–20
20. Quinn N, Knifton L (2005) Promoting recovery and addressing
stigma: mental health awareness through community develop-
ment in a low-income area. Int J Ment Health Promot 7(4):37–44
21. Rethink (2004) Reducing stigma and discrimination. What works.
Conference Report. http://www.rethink.org
22. Rooney R (2005) Explanatory models of mental health and
reducing stigma among people from CALD backgrounds:
towards a model of culturally sensitive mental health care.
http://www.mmha.org.au/MMHAPublications/Synergy
23. Sheikh S, Furnham A (2000) A cross-cultural study of mental
health beliefs and attitudes towards seeking professional help.
Soc Psychiatr Psychiatr Epidemiol 35(7):326–334
24. Tabassum R, Macaskill A, Ahmad I (2000) Attitudes towards
mental health in an urban Pakistani community in the United
Kingdom. Int J Soc Psychiatry 46(3):170–181
25. Taha A, Cherti M (2005) Caught between stigma and inequality:
Black & Minority Ethnic Communities and mental well-being in
Kensington & Chelsea and Westminster: BME Heath Forum and
the Migrant & Refugee Communities’ Forum. http://www.
westminsterpct.nhs.uk/pdfs/caught_between_stigma_and_inequality.
pdf
26. Tilbury F, Slee R, Clark S, O’ Ferrall I, Rapley M (2004) Lis-
tening to Diverse Voices: understandings and experiences of and
interventions for depression among East African migrants.
http://www.mmha.org.au/MMHA/Publications/Synergy
27. Weiss MG, Jadhav SJ, Raguram R, Littlewood R (2001) Psy-
chiatric stigma across cultures: local validation in Bangalore and
London. Anthropol Med 8(1):71–87
28. Wong L, Richman J (2004) Chinese Understanding of Diankuang
in a Metropolitan City in the United Kingdom. Int J Ment Health
32(3):5–30
29. World Health Organisation (2002) Nation for mental health final
report. World Health Organisation Department of Mental Health
and Substance Dependence http://www.who.int/mental_health/
media/en/400.pdf
30. Wynaden D, Chapman R, Orb A, McGowan S, Zeeman Z, Yeak
S (2005) Factors that influence Asian communities’ access to
mental health care. Int J Ment Health Nurs 14(2):88–95
31. Yeung E (2004) Endurance: Improving accessibility to mental
health services for Chinese people. Training manual/resource
pack, 2nd edn. Merseyside Health Action Zone, Liverpool