Enablers of Mental Illness Stigma: A Scoping Review of Individual Perceptions

Gyamfi, Sebastian; Forchuk, Cheryl; Booth, Richard; Luginaah, Isaac

doi:https://doi.org/10.1155/2024/8191281

Mental Illness

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Abstract Introduction Materials and Methods Results Discussion Limitations Conclusion Appendix Data Availability Conflicts of Interest Acknowledgments References Copyright Related Articles

Review Article | Open Access

Volume 2024 | Article ID 8191281 | https://doi.org/10.1155/2024/8191281

Enablers of Mental Illness Stigma: A Scoping Review of Individual Perceptions

Sebastian Gyamfi,¹Cheryl Forchuk,^2,3Richard Booth,^2,3and Isaac Luginaah⁴

Academic Editor: Stefania Chiappini

Received23 Oct 2023

Revised20 Feb 2024

Accepted17 Apr 2024

Published29 Apr 2024

Abstract

Introduction. Stigma is noted to be one of the greatest barriers to the recovery of persons with mental health problems. Stigma has been acknowledged as both an individual and a social orchestration that has an overpowering impact on the social standing of marginalized persons in a society. This study examined the extant literature to ascertain if any evidence(s) suggested a relationship between perceived public attitudes, religious and cultural beliefs, and structural violence in perpetuating stigma against persons with mental illness. Method. We applied a five-step scoping review framework by Arksey and O’Malley to examine evidence in the literature that suggests relationships between perceptions, religious and cultural beliefs, and structural violence in perpetuating stigma. The researchers systematically conducted a literature search from six databases, including CINAHL, Ovid MEDLINE(R), ProQuest Dissertations & Theses Global, Sociology Collection, PsycINFO, and Sociological Abstracts, using search terms that included stigma, mental illness, perception, religious and cultural beliefs, and structural violence. Results. An initial search in six databases yielded 1223 articles. Checking in the Google Search engine yielded 30 more articles. After removing 25 duplicates, 1198 articles remained for title and abstract screening. After a full-text review, 1143 articles were removed. Overall, 30 articles were selected for data extraction. Thematic analysis of the extracted data resulted in three main themes. These include perceptions about mental illness, perceptions about stigma and discrimination, and forms of stigma perception. Conclusion. This study revealed that individual perceptions of public attitudes contributed to their construction of stigma. It is incumbent on everyone to play their part in mitigating all the negative outcomes that stigma brings, especially to persons with mental illness.

1. Introduction

Stigma is characterized by five interrelated negative attributes of labeling, stereotyping, separation (of “us” and “them”), status loss, and discrimination that is underpinned by power relational difficulties between the powerful who see themselves as normal compared to the stigmatized [1].

In certain jurisdictions, stigmatizing behaviors and attitudes have been linked to the long-term influences of historical traditions underpinned by the people’s religious and cultural belief systems [2]. The lives of some people with mental illness (PWMI) are worsened by religious and cultural belief systems that inherently legitimize and justify the unequal social positioning of these persons with the illness. Stigma leads to public labeling, group stereotypes, prejudices, loss of social status and self-worth, and negative implications for social relationships [3] and overall health and well-being.

Aside from stigma and its sequela, recent documentation points to the influences of religious, cultural, and structural violence perspectives of the public towards persons that society perceive as different, including individuals with mental health problems [4]. We argue that these factors impact perceptions of PWMIs in relation to the intrapersonal, interpersonal, institutional, and systemic mechanisms that underpin the distribution of power and resource disparities across the lines of gender, economic and social class, individual health status, and group identity. These social inequities ultimately lead to structural violence (social and psychological harms that result in permanent disability or death).

The factors that comprise the root causes of stigma and the perpetuation of social and health inequities towards marginalized populations appear diverse, complex, interdependent, and dynamic (continuously changing). According to the National Academies of Sciences, Engineering, and Medicine [5], the root cause of health inequity is the unequal allocation of power and resources that relates to the social determinants of health in terms of goods, services, and societal attention, which manifest as unequal social, economic, and environmental.

Ran et al. [6] reviewed forty-one studies regarding the stigma of mental illness and cultural factors in the community. The researchers found that the social stigma attached to mental illness was high in the Pacific Rim region. Cultural factors (including collectivism, familism, religion, and supernatural beliefs) contribute to societal stigmatizing behaviors and attitudes towards persons with mental illness, their relatives, and mental health professionals. Similarly, Misra et al. [7] conducted a systematic review of the cultural aspects of mental illness stigma among three racial and ethnic minority groups (i.e., Asian Americans, Black Americans, and Latinx Americans) from 1990 to 2019. In this review, the researchers found that racialized and ethnic minority groups expressed higher public and self-stigma than White American groups. The study identified structural stigma in the form of service barriers regarding access and quality problems and affiliative (associative) stigma experiences that led to familial stigma and subsequent concealment of a relative’s illness. Misra et al. identified a lack of knowledge about mental illness, cultural beliefs, and negative emotional responses as influential across societies. Therefore, interventions targeting negative cultural perspectives may reduce stigma and service barriers while empowering equity-deserving persons to resist stigma at both interpersonal and personal levels.

Our initial gleaning of the extant literature gave us indications that there was a paucity of empirical research evidence on the subject matter. Even though there is substantial evidence of general research on stigma, to our knowledge, no empirical research globally maps unique concepts such as religious, cultural beliefs, and structural violence perspectives on stigma and mental illness. This scoping review examines and synthesizes the extant literature to ascertain if there is any evidence(s) in the literature that suggests a relationship between perceived public attitudes (individual perceptions), religious and cultural beliefs, and structural violence in perpetuating stigma against persons with mental illness.

2. Materials and Methods

Scoping review processes assist the researcher in analytically reinterpreting the existing literature. Religious and cultural beliefs and structural violence perspectives vis-à-vis stigma are gaining grounds in mental health. We undertook this scoping review to examine the empirical literature to ascertain the extent of research activity regarding the chosen concepts and to identify gaps in the literature. The scoping review method allowed the researchers to incorporate various studies, summarize empirical data to address the research question(s), and generate and disseminate findings to inform future research [8]. In the current review, we applied a five-step scoping review framework by Arksey and O'Malley [8]. The steps include (1) identification of research question(s), (2) identification of relevant studies, (3) selection of included studies, (4) data extraction, charting, and summarization, and (5) data collating, summarizing, and reporting of results.

2.1. Step 1: Identification of Research Questions

Before starting the search for relevant studies, the primary author submitted the research questions to the other coauthors with various expertise in the subject area for vetting and approval. The review addressed the overarching research question: is there empirical evidence suggesting a relationship between perception, religious and cultural beliefs, and structural violence in perpetuating stigma against persons with mental illness? Specifically, the study sought to address the following three subquestions: (a)What does the extant literature say about the relationships between individual perceptions, religious and cultural beliefs, and mental illness stigma?(b)Is there any evidence about the relationship between structural violence and mental illness stigma?(c)What is the evidence about the relationship between religious and cultural beliefs and structural violence?

2.2. Step 2: Identification of Relevant Studies

With the assistance of a librarian, the researcher initially identified search terms and their synonyms for all key concepts of the study topic. Search terms were modified for each database before the search began. The researchers widely and systematically conducted literature searches from six databases including CINAHL, Ovid MEDLINE(R), ProQuest Dissertations & Theses Global, Sociology Collection, PsycINFO, and Sociological Abstracts. The keywords and their synonyms that were used in the search include the following: Stigma (Attitudes to Mental Illness, Stereotyping, Prejudice, Discrimination, self-stigma, internalized stigma, social stigma, structural stigma, institutional stigma, associative stigma, stigma by association, family stigma health professional stigma), Mental illness (Mental Disorders, Psychiatric Disorder, Mental Patients, Mentally Challenged, Psychiatric Patients, persons with mental illness, people with mental illness), Perception (knowledge, attitude, awareness, social perception, individual perception), religious and cultural beliefs (Beliefs, Religious beliefs, Religious and cultural beliefs, Culture, Religion, Cultural beliefs, Practices), and Structural violence (Violence, Institutional violence, Social injustice).

During the literature search, we “exploded” some key terms in the MEDLINE and PsycINFO databases to direct the system to search for the given key terms and all other more specific terms linked to the original term. Where applicable, we enter the search terms step by step with Boolean search operators (OR and AND) to appropriately broaden or narrow the search results. Where appropriate, Medical Subject Headings (MeSH) terms were used in the search process to optimize results. See an exemplar search strategy in the appendix for details.

We also conducted a manual search on Google to ensure that the review process was thorough. Peer-reviewed, full-text empirical studies, including primary research, qualitative, quantitative, or mixed methods that were published in both health and nonhealthcare databases from January 01, 2009, to May 31, 2023, were included in the review. An initial search in the six databases yielded 1223 articles. Again, checking in the Google Search engine yielded 30 more additional articles. After removing 25 duplicates, 1198 articles remained for the next steps of title and abstract screening. Table 1 shows the six main concepts and their definitions of how we have conceptualized them in relation to the current review.

2.2.1. Inclusion Criteria

A study was included in the review if it met the following criteria: (1) involved a population of people with mental illness (such as schizophrenia and related disorders and mood/affective disorders, e.g., depression and bipolar disorders, substance-related disorders, and anxiety disorders), (2) people with mental illness aged 18 and above, (3) included some or all these terms “public perception,” “mental illness,” stigma, “religious beliefs,” “cultural beliefs,” “structural violence,” and/or their synonyms, (4) was conducted anywhere in the world, (5) primary research, (6) published since 2009, and (7) published in English.

We excluded studies that had (i) populations other than people with mental illness, (ii) participants under 18 years, (iii) articles published outside the stated publication date and in different languages other than English, and (iv) abstracts only. Table 2 details the set criteria for including papers in the study.

2.3. Step 3: Selection of Included Studies

Having removed duplicates from the initial search results, two researchers, GS and JA, independently checked the titles and abstracts of the papers in line with the set inclusion criteria. After the title and abstract screening of the 1198 articles, the two researchers met and reconciled any discrepancies that each identified before arriving at the final set of articles for full-text review. Finally, the researchers agreed to remove 1143 articles based on various reasons, including papers with nonpatient populations, participants under 18 years, articles published before 2009, and in different languages, not full text, and participants’ a diagnosis that did not meet the inclusion criteria of the current review. The two researchers further conducted a full-text review of the remaining 55 articles independently, after which they met and resolved any conflicts related to the final set of articles each of them had chosen for data extraction. After the full-text review, 26 articles were eliminated, leaving 29 articles for data extraction. Of the 26 excluded papers, 10 involved a wrong population, 4 were not full text, 8 were out of date specification, and 4 were not primary research (i.e., 2 = opinion papers; 2 = systematic reviews). A manual search of the reference list of the selected articles yielded one more article. We manually searched the included studies to ensure that all possible articles related to the research question were identified. Therefore, the final list of articles selected for data extraction was 30. At the data charting stage, only one researcher, GS, performed all data extraction procedures for the included papers with input from the rest of the research team. See Figure 1 for details of the article selection process as presented in the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) flow diagram [15].

2.4. Step 4: Data Extraction/Charting and Summarization

Before commencing data extraction, we first created a Microsoft spreadsheet with the following subheadings: study number (#), author(s), publication year, country and title, objectives/hypotheses, study design, population (sample size and characteristics), measurements, and main results. This helped us to organize our data and to aid subsequent summarization of the results. Table 3 summarizes the extracted study data.

2.5. Step 5: Data Collating, Summarizing, and Reporting of Results

This step entailed reporting the extracted evidence from the 30 included studies. Having identified the appropriate studies from the various databases, we extracted data from the selected articles that met our set criteria. We then performed thematic content analysis on the extracted data drawing on Braun and Clarke [46] framework. SG (the primary author) read through the initial data for familiarization. Upon a second reading, the investigator initiated open coding (developing and modifying codes along the process). The coded text was reduced by listing all keywords or ideas on a separate Microsoft sheet, after which all codes were defined into common groups (categories) and subcategories (themes). The analyzed data was subsequently presented to the rest of the study team for review and validation. The emerging themes were integrated with their accompanying text and then summarized into a narrative report. In all, three major themes emerged. Any use of direct quotes from the primary studies to support the themes?

Consider stage 6: consultation exercise.

3. Results

3.1. Characteristics of the Included Studies

Considering the year and number of publications, the review identified 30 studies that were published from 2009 to 2023 and includes 2009 = 3 (10.71%); 2010 = 1 (3.57%); 2011 = 3 (10.00%); 2012 = 2 (6.67%); 2013 = 4 (13.33%); 2014 = 6 (20.00%); 2015 = 3(10.00%); 2016 = 2 (6.67%); 2017 = 1 (3.33%); 2018 = 1 (3.33%); 2019 = 2 (6.67%); 2021 = 1 (6.67%); and 2022 = 1 (3.33%).

In terms of country and the number of studies, we observed that among the 30 included studies, 25 were conducted in only one country In contrast, five (5) were conducted in multiple countries and in multiple sites. The single country research sites include Thailand [39], Uganda [37], Ghana [2, 17, 23, 42], United States of America (USA) [31, 35, 38, 44], Canada [33], China [30, 32], Nigeria [34], Australia [45], Ethiopia [16, 18, 19], United Kingdom (UK) [24], India [40], Sweden [27], Iran [25], Spain [26], and Hong Kong [29]. Aside from the two studies [25, 44] that a single researcher conducted, two or more researchers conducted the rest of the included studies.

In relation to the included studies that were conducted in multicountry/multisites, the following five (5) studies were identified: Brohan et al. [20], 13 European countries, i.e., Belgium, Croatia, Estonia, Finland, Greece, Italy, Lithuania, Macedonia, Malta, Poland, Romania, Spain, and Sweden; Brohan et al. [20], 14 European countries, i.e., Bulgaria, Croatia, Czech Republic, Estonia, Greece, Lithuania, Macedonia, Poland, Romania, Russia, Slovenia, Spain, Turkey, and Ukraine; Thornicroft et al. [43], 27 countries involving European, Asian, and North and South American, i.e., Spain, India, Poland, Greece, Malaysia, Germany, Tajikistan, the UK, Canada, Belgium, Italy, Switzerland, Netherlands, Austria, Norway, Slovenia, Lithuania, Bulgaria, Slovakia, Portugal, Romania, Turkey, Cyprus, Finland, France, the USA, and Brazil; Harangozo et al. [28], 21 countries including Bulgaria, Hungary, Lithuania, Poland, Romania, Slovakia, Slovenia, Cyprus, Finland, France, Germany, Greece, India, Italy, Malaysia Netherlands, Norway, Portugal, Spain, Switzerland, and the UK; Brouwers et al. [22], 35 countries involving Belgium, Bulgaria, England, Finland, France, Germany, Greece, Hungary, Italy, Lithuania, Netherlands, Portugal, Romania, Scotland, Slovakia, Slovenia, Spain, Turkey, Australia, Brazil, Canada, Croatia, Czech Republic, Egypt, India, Japan, Malaysia, Morocco, Nigeria, Pakistan, Serbia, Sri Lanka, Taiwan, Tunisia, and Venezuela; and Sun et al. [41], five countries involving China, Korea, Malaysia, Singapore, and Thailand.

With regard to the area(s) of focus of the 30 studies, nine studies focused on perceptions (beliefs) of stigma and discrimination associated with mental illness [2, 18, 19, 27, 37, 38, 40, 41, 45], while four studies each examined internalized stigma [16, 25, 26, 35] and severity of anticipated and experienced discrimination [22, 24, 29, 43], respectively.

In another vein, two studies each concentrated on three areas. These include patient attitudes and perceptions about mental illness [17, 39], experienced stigma [30, 32], and stigma resistance and empowerment [20, 21]. The remaining research areas had one study each concentrating on them. These include how persons with mental illness were stigmatized and discriminated against [23], experienced discrimination [28], impact of stigma and discrimination [34], coping with stigma and support strategies [42], and influences of structural stigma on mental illness in relation to attitudes towards treatment seeking and quality of life [44].

About 25 (83.33%) of the studies used quantitative cross-sectional designs with self-reported questionnaires, while only 5 (16.67%) of the articles used qualitative methods with in-depth one-on-one interviews to study participants. The overall population of participants involved in the 30 studies was 9554. All 30 studies recruited both males and females. While 4675 (49.35%) were male, 4799 (50.65%) were female. Only one (0.01%) participant reported being transgender. We, however, note that 68 (0.75%), i.e., 18, 10, and 40 participants from Thailand, Ghana, and Uganda, respectively, did not indicate their gender. The total number of married or cohabitated participants was 2338 (25.78%). The rest were either single, divorced, separated, or widowed.

Regarding participant education and employment, 6335 (69.85%) had some form of education from primary to university. In comparison, 3038 (33.50%) of the participants had some form of job, including full-time, part-time, and volunteer work. The remaining participants were either retired, unemployed, or students. Out of the 30 studies, only 6 (20%) reported on the religious denomination of their participants. Participants’ diagnoses as indicated by the various studies included schizophrenia spectrum disorders, 3110 (34.39%); mood/affective disorders, 3331 (36.73%); neuropsychiatric disorder, 427 (4.71); substance use disorders, 34 (0.43%); anxiety disorders, 81 (0.89%); adult attention-deficit/hyperactivity disorder (0.154%); eating disorder, 7 (0.08%); and personality disorder (0.03%). A few participants, however, failed to indicate their diagnosis.

4. Study Themes

The current review examined factors that contribute to the perpetuation of mental illness stigma among persons with mental illness globally. Thematic content analysis of the 30 included studies resulted in three main themes. These include (1) perceptions about mental illness, (2) perceptions about stigma and discrimination, and (3) forms of stigma perception (see Table 4 for details).

4.1. Perceptions about Mental Illness

Perception influences awareness and ways of thinking (opinion formation) concerning environmental issues [47, 48]. Such long-standing opinions may lead to the development of societal belief systems, attitudes, values, norms, and behavioral patterns. In relation to the current review, six of the included studies discussed how persons with mental health problems view their illness vis-à-vis public interactions [2, 31, 37, 39, 40, 42]. The subthemes related to perceptions about mental illness include the nature of illness, perceived etiology/causality, and the nature of treatment modalities for mental illness.

4.1.1. Perceived Nature of Illness

Three studies [31, 37, 39] presented evidence on how some individuals described their illness. Some persons with mental illness felt that their symptoms were abnormal. Some common symptoms among participants increased their awareness of a potential mental illness. For instance, a Thai study by Sanseeha et al. [39] found that most PWMIs were usually aware of their symptoms. Participants felt that their symptoms including physical, behavioral, cognitive, and emotional aspects were abnormal. They believed the abnormality was a chronic condition [31, 37, 39] and required continuous medication and treatment [39]. In Sanseeha et al.’s study, it came out that even though some participants believed that their drugs helped alleviate the symptoms, they still felt they might not fully recover. Some openly said they expected to relapse and did not believe they would recover. In another vein, some participants disclosed that members of the public believed that mental illness is contagious (emphasizing epilepsy), inheritable (going from generation to generation), and chronic (that PWMIs do not recover from the illness). This belief limited some participants’ life chances, for example, in marriage [37].

4.1.2. Perceived Etiology/Causality

Perceptions about the causes of mental illness were varied. Six studies [2, 31, 37, 39, 40, 42] identified some perceived causes of mental illnesses among PWMI. These factors included biological, psychosocial, trauma, and religious, cultural, and traditional beliefs.

Some participants believed biological factors contribute to mental illness [31, 39, 42]. Some of these biological factors include head trauma and neurotransmitter deficiencies through brain abnormalities [31], complications from drug use [31, 40], improper diet [31], and genetic inheritance [31, 39]. Some patient participants disclosed that their relatives told them that their illness was passed on to them by their ancestors (grandparents through genetics) [31, 39].

Psychological stress and social distress were cited as key causes of mental illnesses. Perceptions (beliefs) about the causes of mental illness have been diverse. Some PWMI attributed their illness to negative personal losses including marital or family problems or other family losses [31]. Others have cited the psychological trauma associated with the sexual abuse they experienced as a precursor to their illness [31]. Several participants attributed the cause of mental illness to distress, anxiety, and an overactive mind [31, 37, 39]. Some participants also mentioned poverty and loss of job as a cause of mental illness due to the distress associated with not being able to care for themselves and their family in terms of food, education, or even transport to the hospital to seek healthcare [37]. A social causation was also mentioned. For instance, a few attributed their illness to specific events, such as the breakup of an intimate relationship [2, 37].

While some people had no idea about the cause of their illness [42], others expressed the conviction of what they think caused mental illness. Participants believed that the causes of their illness were supernatural powers such as black magic, bad karma from the past, evil spirits from ancestors, and demons [2, 39, 42]. Supernatural power (use of black magic) is believed to affect one’s psychological or mental behaviors, including emotions, to deviate from normality. The participants believed this happened, especially if someone disliked you or envied you for your success at work. Most participants mentioned that the public still holds onto supernatural and traditional cultural explanations for mental illness, such as being possessed by evil spirits, as a punishment or curse due to wrongdoing. They also believed that mental illness occurs due to curses, witchcraft, or when clan spirits or social spirits get angry with someone [37, 39]. Most participants considered or were told that the problem was spiritual and reflected Christian and traditional thinking around spirituality. Some also attributed their illness to God’s punishment for previous poor behavior [2, 42].

4.1.3. Nature of Treatment Modalities

Despite evidence of people seeking orthodox treatment, the influences of tradition and faith in treatment modalities were pervasive among some studies, mostly from the LMICs. Four studies, including Gyamfi et al. [2], Lin [31], Quinn and Knifton [37], and Tawiah et al. [42], discovered some modes of treatment that PWMI sought in their community. There is no doubt that one’s belief system impacts their treatment choices. For some of the participants, the best way of dealing with such problems was to seek traditional treatments or faith “cures” from faith healers, including pastors [2, 31, 37, 42], imams, fetish priests, and herbal medicine practitioners [37]. For instance, a Ugandan study by Quinn and Knifton [37] underscored that traditional beliefs often coexist with social, biomedical, and religious explanations regarding cause and treatment seeking. For many participants in Christian and Muslim communities, mental health problems had a religious cause attributed to sin or the “will of God.” Many sought help from their Christian churches [2, 31, 37, 42]. Those with a traditional view of being cursed or invaded by evil spirits paid community healers to rid them of the curse or evil spirit [2, 37]. Eventually, all sought orthodox or hospital care, either on the advice of a close relation or the church.

4.2. Perceptions about Stigma and Discrimination

Public (social) stigma is widespread with associated negative attitudes from society. All 30 included studies [2, 16–35, 37–45] reported on how persons with mental illness appraise public attitudes towards them. This evidence of stigmatization and discrimination was mostly observed during interactions with family members, friends and community members, health professionals, and during contact with employers and work colleagues. Under this theme, we identified four subthemes: labeling and stereotyping, prejudice, public discrimination, and rejection sensitivity.

4.2.1. Labeling and Stereotyping

Eleven out of the 30 included studies reported on labeling and stereotyping. The 11 studies included Assefa et al. [16], Bifftu and Dachew [19], Dako-Gyeke and Asumang [23], Ghanean and Jacobsson [25], Gyamfi et al. [2], Li et al. [30], Lin [31], Lv et al. [32], Quinn and Knifton [37], Sanseeha et al. [39], and Shrivastava et al. [40]. The participants spoke about self-labeling, public labeling, and media labeling.

Regarding self-labeling and stereotyping, some persons described their symptoms as unpredictable, while others described themselves as violent [25]. For instance, in Thailand, participants described their symptoms as “phee-kuow’ in Thai, meaning possessed, uncontrollable situation [39]. In Ethiopia, Bifftu and Dachew [19] also found that most participants stereotyped themselves by agreeing with public perceptions that PWMIs are dangerous and unpredictable. Some described themselves as looking strange and that their life was “spoiled” [32].

In relation to public or social labeling and stereotyping behaviors, some individuals reported public tagging attitudes in various jurisdictions. Some felt branded by neighbors through their actions [31]. A section of the public described PWMI as different [39]. The public described them as “phee-bha” in Thai (meaning, insane). In certain jurisdictions, the public described every mental health issue as “madness” [2, 37]. Others describe them as “mad” [2, 23]. Public perceptions of dangerousness [30, 37], unpredictability [23, 37], and being described as funny were also pervasive in society [2, 37]. Some members of the public also described PWMI as crazy [2, 23] and violent [23]; as such, they would be scared and careful when dealing with them [23].

The media also promoted negative publicity (media stereotyping) by using derogatory tags in describing PWMI. This largely contributed to the discrimination and subsequent stigma that some PWMI faced [2, 40]. Such public perceptions of dangerousness created social distance, isolation, and withdrawal, leading to a communication gap between people with mental health problems and the rest of society.

4.2.2. Prejudice

Four studies of 30 articles mentioned negative and unjustified public attitudes towards individuals with mental illness [31, 37, 39, 40]. Most PWMIs were rejected several times [39, 40]. The public distrusted them due to their illness [39]. PWMIs were also blamed for their illness [31, 37]. Participants heard offensive comments from family and neighbors alike [40]. Some family members described their sick relatives as a disgrace to the family [31]. The continued public branding and judgment increased perceived public (social) stigmatizing attitudes and shame associated with having a mental illness. In some jurisdictions, the public believed that patients might have committed a serious crime or sin that led to their predicament. These misperceptions were linked to religious and traditional cultural beliefs/explanations upheld by the public [37]. The members of the public also perceived the patients as “figures of pity” needing sympathy and special consideration [37].

4.2.3. Public Discrimination

Some participants experienced unfair treatment from others based on their illness. Out of the 30 studies, twenty-one of them identified discrimination from the public as a key factor that contributes to perceptions of stigma among PWMI [2, 16, 17, 20–22, 24, 25, 27–30, 32, 34, 35, 37, 39, 40, 42, 43, 45]. In some cultures, shame, guilt, embarrassment, and loss of respect (for individuals and family) are powerful factors shaping and influencing how people feel and respond to stigma and discrimination. Rates of discrimination in society, both anticipated and experienced discrimination, were consistently high across countries [2, 17, 20–22, 24, 27–30, 34, 35, 39, 40, 42, 43, 45]. One of the most frequent items for experienced discrimination was being unfairly treated in dating or intimate relationships [2, 34, 40, 43], or being avoided or shunned by neighbors and family [27, 30, 37, 45].

In another vein, some of the included studies involved [2, 17, 20–22, 24, 27, 29, 30, 34, 35, 39, 40, 42, 43, 45] identified anticipated discrimination as a key factor that affects the life aspirations of some PWMI. Both experienced discrimination and anticipated discrimination were widespread. For instance, Brouwers et al. [22] studied participants with major depression in 35 countries. Most of these participants encountered experienced and anticipated discrimination in the work setting. In highly developed countries, nearly 60% of respondents stopped applying for work, education, or training because of anticipated discrimination. Participants in countries with a very high Human Development Index (HDI) (i.e., higher standard of living) reported more anticipated and experienced discrimination than those with moderate or low HDI. However, two studies [43, 45] reported a lack of negative treatment, otherwise known as positive discrimination, among some participants who received various forms of special support from the public.

4.2.4. Rejection Sensitivity

Rejection sensitivity is a psychological response characterized by chronic anxious expectations of rejection that PWMI portray during social interactions. Rejection sensitivity is a coping method for some people to guard against potential threats in their social environments [49]. Only two out of the 30 included studies reported on rejection sensitivity among PWMI [2, 38]. Stigma and discrimination are not experienced equally by PWMI [37, 38]. Such differences may be due to existing public prejudice [2], higher levels of perceived societal stigma stress appraisal among PWMI [38], and high level of experienced discrimination [2, 22, 24, 27, 28, 30, 34, 35, 39, 40, 42, 43, 45].

4.3. Forms of Stigma Perception

Stigma and discrimination are not experienced equally [37, 38]. Stigma and discrimination are also experienced or perceived differently depending on who and what is involved in the process. In the current review, 15 of the included studies [2, 16, 22, 23, 26–28, 30, 34, 35, 37, 40, 41, 44, 45] identified various ways in which stigma was portrayed among PWMI. The five subthemes under “forms of stigma perception” include family-orchestrated stigma and discrimination, structural/institutional stigma and discrimination, health professional stigma, associative stigma, and internalized/self-stigma.

4.3.1. Family-Orchestrated Stigma and Discrimination

People with mental illness experience stigma and discrimination in various forms by their family members. Some participants bemoaned the attitude of some family members as disturbing and regarded as the most common source of discrimination and stigma distress towards PWMI. Eight studies out of 30 [2, 16, 23, 27, 28, 37, 40, 41] reported on this phenomenon. Some participants claimed their families blamed them for causing their illness [23, 37]. Some relatives also accused participants of falling sick because they associated themselves with bad friends [23], while some family members believed the sick relatives had sinned or offended some spirits and, therefore, their ancestors were punishing them for this [2, 23, 37]. Some studies also reported on how families abused the human rights of their sick relatives. For instance, the impending shame of having a relative with mental illness made some members distance themselves by hiding, separating, or locking them away from social interactions [23, 37]. Similarly, some individuals revealed that their partners deserted them and sought new companions [23]. Even though perceived family stigma and discrimination were evident, some studies, including Hansson et al. [27] and Shrivastava et al. [40], found low stigmatizing attitudes from some extended family members towards PWMI in marital life, including when trying to raise their own family.

4.3.2. Structural/Institutional Stigma and Discrimination

Institutional discrimination constitutes practices and policies within organizations (formal or informal) that systematically culminate in denying PWMI access to existing resources and opportunities. The participants (patients) observed various incidents of discrimination in their workplaces by employers and employees alike. Nine studies reported that discrimination against PWMI was widespread in the workplace [2, 22, 30, 34, 35, 37, 40, 44, 45]. PWMI had been denied employment and even volunteered once they disclosed their illness [37, 44, 45]. Negative media reportage about people with mental illness is common in certain jurisdictions, contributing to creating and perpetuating unfair institutional or organizational policies. Two studies [2, 37] reported the influence of media pronouncements that contributed to the phenomenon.

4.3.3. Health Professional Stigma

Health professionals also contributed to the stigma process in several ways. There have been several reported cases of experienced discrimination during treatment seeking for PWMI in both physical and mental healthcare settings globally. Nine of the included studies reported on the behavior of health professionals towards PWMI [2, 16, 21, 27, 28, 33, 35, 40, 45]. For instance, some patients reported how their doctors and nurses disrespected and looked down on them by refusing to tell them what was wrong when they wanted an explanation for their illness. These behaviors from health professionals contributed to the low health-seeking behaviors among PWMI [2, 33, 37]. According to Brohan et al. [21], a lack of knowledge about one’s illness predisposes the individual to self-stigma than those who become aware of and accept their illness. Health professionals were also rude [33] and disrespected their clients [28, 45]. Some professionals perceived individuals with mental illness as less intelligent, irrespective of their education level [45]. Despite the negative report on health professional behavior, two included studies [28, 45] spoke positively in terms of the support that some health professionals gave to their clients during treatment seeking.

4.3.4. Associative Stigma

Some family members and health professionals had their fair share of negative public attitudes [50]. For instance, some studies claimed that neighbors gossiped, ridiculed, and always pointed fingers at family caregivers and their children suffering from mental illness. Only two included studies identified this experience [2, 23]. Some families reportedly lost their close friends [23]. This is probably one of the reasons why some families either stay away or keep their sick relatives from the public. In most collectivist societies, community members play a large role in choosing a partner. Due to the prejudice around mental illness, most close family members of PWMI reportedly found it difficult to get partners in their community [2, 23].

4.3.5. Internalized/Self-Stigma

Internalized self-stigma is a self-devaluation process characterized by awareness of public stereotypes, agreeing with them, and applying them to the self [51]. There is a high prevalence of perceived stigma that persons with mental illness usually direct at themselves. In this review, 16 studies reported the existence of internalized self-stigma. The studies include Assefa et al. [16], Bifftu and Dachew [19], Bifftu et al. [18], Brohan et al. [21], Brohan et al. [20], Ghanean and Jacobsson [25], González-Sanguino et al. [26], Gyamfi et al. [2], Hansson et al. [27] Lv et al. [32], Oleniuk et al. [33], Oshodi et al. [34], Quinn et al. [35], Quinn and Knifton [37], Sanseeha et al. [39], and Van Horn [44].

Personal responses to discrimination may occur in several ways, including self- or internalized stigma processes. In the current review, some participants revealed that they lost their self-confidence [26, 39] owing to the pervasive social discrimination, leading to feelings of inferiority [39]. Most PWMI frequently expressed feelings of shame [31, 37], guilt [18, 37], depression [18], feeling of worthlessness [37], and isolation [2]. Persons who experienced self-stigma also experienced some form of alienation, experienced discrimination, or social withdrawal [20]. It is worth noting, however, that some PWMI in some of the studies reported low levels of self-stigma in the presence of high stigma resistance and empowerment. The five studies documenting high stigma resistance include Brohan et al. [21], Brohan et al. [20], González-Sanguino et al. [26] Lin [31], and Oleniuk et al. [33].

5. Proposing a Contemporary Stigma Model

Based on our knowledge of the literature so far, we conceptualize and define stigma as “the product of public attitudes and behaviors that characterize labeling, stereotyping, prejudice, cognitive separation, status loss, and discrimination that lead to responses that may include stress and esteem-related appraisal of experienced, anticipated, perceived or personal endorsement of societal actions that are anchored by existing power relational differentials.” (Figure 2) shows the “stigma stress perception appraisal model (SSPAM)” inspired by our new definition of stigma. We believe that religious and cultural belief systems and structural violence perspectives are mostly invisible, powerful tools embedded in social governance structures that create and sustain stigma against vulnerable groups in the form of labels, stereotyping, and prejudice that culminate in a cognitive separation of the “us” versus “them” situation. Once separation (segregation) becomes successful, the vulnerable individuals lose their social status, leading to discrimination. Discriminatory attitudes and behavior from the public lead to coping orientations of rejection sensitivity (a disposition of anxious expectations in which vulnerable persons readily perceive and overreact to social rejection cues). Depending on the extent of rejection sensitivity, the individual may perceive and appraise stigma stress appropriately (as negative or positive) with subsequent impact in their life domain.

6. Discussion

Issues of mental illness, stigma, and discrimination are complex and, therefore, need to be understood in relation to the cultural, social, and economic context of the society in which the affected persons live. Considering this, the current review examined the extant literature to ascertain if there was any evidence suggesting a relationship between perceived public attitudes, religious and cultural beliefs, and structural violence in perpetuating stigma against persons with mental illness.

Perceptions of an individual influence their awareness and opinion formation concerning environmental issues [47, 48]. Such long-standing opinions may lead to developing societal belief systems, attitudes, values, norms, and behavioral patterns.

The review brought to the fore that the perceived influence of religious and cultural beliefs about the causation of mental illness is a well-documented issue, especially among most low- to middle-income countries compared to the high-income ones—revealing a strong underlying influence that traditional faith, including religious and cultural values, plays a significant role in shaping perceptions and attitudes towards vulnerable groups including persons with mental illness [52, 53]. We emphasize, however, that people have varied perceptions about the nature and cause of their illness. For instance, while some studies identified psychosocial and economic factors as mental illness triggers, some acknowledged biomedical including physical and genetic causes. These mixed perceptions also informed the treatment modes that individuals and their families patronized first when sick. For example, while the European and American studies reported mainly on orthodox treatment, the African and Asian studies reported on the mix of traditional faith healing and orthodox health seeking. Despite the strong attributions of supernatural and traditional bases concerning the incidence of mental illness, the role of biomedical and psychosocial causes was evident in the extant literature of both low- to middle-income and high-income countries. The ideological stance of most Western countries leaning more towards the biomedical model in relation to causality and treatment further explains why none of the participants in the studies conducted in Europe and America referenced supernatural or spiritual causes. Generally, the Western model of mental illness causality and treatment is incongruent with beliefs in supernatural causes. This is probably one of the reasons why most stigma frameworks do not inculcate religious and cultural perspectives to help explain stigma processes linked to mental illness.

Just as has been found in other reviews, findings from our study confirmed that public stigma and discrimination were widespread with a consequential negative overall effect on PWMI and their close associates, including family members, friends, community members, health professionals, and during contact with employers and work colleagues [54–56]. The review again confirmed the existing literature that even though most PWMI experienced various forms of stigma, the nature of one’s illness in relation to behavioral symptoms contributed to the social stigma and discrimination they encountered [57]. The participants’ stigma perceptions included family stigma and discrimination, structural/institutional stigma and discrimination, health professional stigma, associative stigma, and internalized/self-stigma. Overall, individuals with higher levels of public stigma were likely to have higher levels of experienced stigma [58].

The review highlights evidence of labeling and stereotyping, prejudice, public discrimination, and rejection sensitivity in relation to stigma and discrimination from the public. These negative attitudes and behaviors were mostly observed during interactions with family members, friends, community members, health professionals, employers, and work colleagues. As found in our study, the consequence of stigma and discrimination usually takes various forms including economic, social, and psychological effects, leading to negative outcomes of social separation (distancing or exclusion) and status loss due to perceived devaluation from society relating to the individual’s incapacity.

According to Link and Phelan [1], mental illness stigma could be explained by five co-occurring components: labeling, stereotyping, separation, status loss, and discrimination. Link and Phelan further contend that labeling or tagging comes from a social process of categorization that are underpinned by power differences. Elsewhere, Corrigan et al. [59] have also argued that labels such as “dangerous,” “violent,” and “unpredictable” entrench stereotyping behaviors and pave the way for discrimination and other sequels of stigma to occur. Once the individual applies these stereotypes to the self, they internalize and experience self-stigma, leading to negative implications that include self-esteem problems, social withdrawal, joblessness, partner loss, and low quality of life.

7. Implications

More than a decade ago, some authorities, including Corrigan [60] and Kelly [61, 62], argued that mental illness stigma was an issue of injustice that culminated in the harm or death of persons experiencing mental health problems and, as such, called for action towards ameliorating this predicament. We, therefore, undertook the current review to ascertain whether there is empirical evidence in the literature that suggests a relationship between perception, religious and cultural beliefs, and structural violence in perpetuating stigma against persons with a history of mental illness. Even though the review established substantial evidence of research on stigma as perceived by PWMI, no empirical research globally mapped the unique concepts of structural violence and religious and cultural perspectives on mental illness stigma. This gap has implications for future stigma research. We believe that successful primary research in this area will create avenues for further evidence towards unique interventional studies that would stimulate enhanced social advocacy while streamlining changes in antistigma policies and strategies.

8. Limitations

The current scoping review enabled the researchers to systematically search from various databases to reinterpret the existing literature analytically. Again, the scoping review method allowed us to incorporate various study designs and summarize data (including published and grey literature) to address our research questions. Despite these strengths, the review also had limitations. The fact that we limited the age of the study population to 18 years and above excluded other studies that had populations outside this age bracket, leading to the loss of information relating to children and adolescents who experience stigma due to their illness. Future reviews should examine the perspectives of children and adolescents in relation to stigma and its impact on this population. Again, the fact that we restricted the study to articles published in the English language from 2009 to 2023 might have excluded some relevant articles. Even though we consulted with experts who were members of the research team (regarding research question formulation and the analysis process), our inability to undertake consultation with PWMIs might have impacted our findings. Even though the consultation stage is optional [8], it could have further enriched the study findings had it been fully explored to the latter. The impact of this limitation is reduced by the authors’ continuous engagement and expertise in the subject matter for a balanced reporting of the findings. That said, it was also relevant that we situated the review within a certain context and time frame of recency to inform future stigma research paths. In all, the effective application of the five-step scoping review framework by Arksey and O'Malley [8] allowed us to address our research questions to generate findings that could be vital to future primary research.

9. Conclusion

The consequence of existing power differentials and the negative public misconception about mental illness is the inherent basis for the exclusionary attitudes and behaviors that society perpetuates against the PWMI. Interventions that encourage personal empowerment could play a vital role in overcoming the stigma associated with mental illnesses.

The current review identified negative media reportage about mental illness as common in certain jurisdictions on television, radio, and newspapers as reinforcers of negative stereotypes through abusive language and negative labeling. Such sustained negative public views strengthen inequity, making PWMI develop negative attitudes towards themselves and others in their community. Eventually, stigma directed at the self prevents people from seeking help, leading to further complications that fuel more self- and public stigmatizing behaviors.

Appendix

Database: Ovid MEDLINE(R) results on May 31, 2023

Search strategy:

--------------------------------------------------------------------------------

1 exp Mental Disorders/ or exp Stereotyping/ or exp Social Stigma/ or exp Prejudice/ (1204273)

2 mental illness.mp. or exp psychiatric disorder/ or “persons with mental illness” (133656)

3 1 and 2 (61349)

4 belief.mp. or “Health Knowledge”, or exp Attitudes, or exp Perception/ or awareness (166741)

5 exp Culture/ or exp cultural (31803)

6 exp Religion/ or "Religion and Culture"/ or “Religious and Cultural (19951)

7 exp Violence/ or “Structural violence” or “Social injustice” or “Institutional violence” (29289)

8 Social Discrimination/ (950)

9 3 or 8 (62228)

10 4 or 5 or 6 (207832)

11 9 and 10 (2811)

12 7 and 11 (42)

Data Availability

Data sharing is not applicable to this article as no new data were created or analyzed in this study.

Conflicts of Interest

The authors want to state that they have no competing interests to declare.

Acknowledgments

We thank all library assistants for their support during the literature search process.

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Copyright © 2024 Sebastian Gyamfi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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