This study explored the sociodemographic correlates of the public stigma of mental illness using a large representative sample of the Chinese population in Hong Kong. The findings highlighted that the female gender, older age groups, and lower education levels are associated with significantly higher stigma about mental illness. There was no evidence of differential public stigma among populations of various occupations; however, retired individuals and homemakers are likely to have higher public stigma. The strength of the association between mental health literacy and public stigma varied by age and education level, suggesting that the effect of destigmatising programs through improved mental health literacy might vary with different age groups and educational backgrounds. People aged 50 years and above with lower education levels indicated the strongest link between mental health literacy and public stigma.
The finding that individuals with lower education levels are likely to show more negative stigmatising attitudes is consistent with those of previous research [33, 34]. However, this conclusion is in contrast with that of a previous study on Hong Kong’s Chinese population [17], which suggested that higher education levels are associated with more stigmatising attitudes towards psychosis. It is possible that the relationship between education level and the stigma of psychosis differs from that between education level and other mental illnesses. While it is generally believed that individuals with higher education levels possess better mental health literacy [35, 36], the association of mental health literacy with the public stigma of psychosis and general mental health illness may be different. In the context of psychosis, it has been consistently reported that an improved biological understanding of psychosis is related to worsening public stigma [37]. A local study showed that improving knowledge about the nature of psychosis rather than its symptoms and treatment can improve public stigma about psychosis [17]. On the other hand, improving knowledge about general mental illness is related with reduced public stigma [9]. In other words, basic mental health literacy generally acquired by individuals with higher education levels is related to a better attitude towards general mental illnesses. However, the biological understanding about psychosis, which also tends to be acquired by individuals with higher education levels, worsens attitudes towards psychosis.
This study, to the best of our knowledge, is the first to report a positive association between age and the public stigma of mental illness among a Chinese population. It further evidence that such a relationship is closely related to educational level and mental health literacy. While nearly half of Hong Kong’s population is older than 50 years, one-third possesses only primary education. The moderation analysis revealed that this group has the strongest positive correlation between mental health literacy and the public stigma of mental illness. Thus, future destigmatising programs should target individuals aged 50 years or above with low education levels. This also possibly explains the little or no effect of mental health education on adolescent attitudes reported in a study by Pinto-Foltz, Logsdon (38). Younger generations are more likely to have acquired basic mental health literacy. Potential generational differences in cultural beliefs are another factor that could explain the age effect on the stigma of mental illness. This argument is supported by an earlier study that highlighted generational differences in family and gender values among the Chinese population [39]. Further research is needed to explore the effect of variation in culture beliefs among different generations on public stigma comprehensively. These findings suggest that destigmatising interventions should adopt different approaches for various generations. Improving mental health literacy could be a more effective approach for older people with lower education levels. This study’s results could guide the development of future targeted anti-stigma campaigns.
The findings of gender effects on the public stigma of mental illness are consistent with those of prior local research, which suggested a relationship between the female gender and more negative stigmatising attitudes in the Chinese population [17, 18]. However, the results contrast with those of studies on other ethnicities, which indicated an association between the male gender and more negative attitudes [14, 40, 41]. These differences can be explained by varying cultural beliefs about mental health stigma. The Asian population is reportedly more susceptible to their cultural beliefs in terms of mental health stigma [42]. Among the Chinese, for example, the public stigma of mental illness is often shaped by cultural meanings embedded in Confucianism, wherein the pejorative aetiological belief in mental illness is more strongly associated with the centrality of “face” [43], fear, shame, cognitive impairment, social community, consensus, and sanction [44]. Further, women are at the lower end of the Confucian hierarchy and are expected to behave exemplarily and obey without complaint, leading to a potentially increased sense of the aforementioned negative perception of mental illness among Chinese women.
While life satisfaction was not the main focus of the correlates under examination, this study is among the few to report an association between life satisfaction and public stigma. To this effect, research has shown that life satisfaction is positively associated with all five stages in Maslow’s hierarchy of needs [45]. This association suggests that individuals with better life satisfaction are more likely to adopt a self-actualising attitude and thus seek knowledge about mental health and adopt a more positive attitude towards mental illness. The present findings, however, are not in line with those of Crowe and Kim [24], who reported no evidence of an association between life satisfaction and stigma. Nevertheless, the authors selected the attitude towards mental health treatment as the outcome variable, which is an indicator of intended help-seeking behaviour. Such behaviours are considered ‘safety needs’ according to Maslow’s hierarchy of needs, and the safety needs stage has a weaker correlation with life satisfaction than the self-actualisation stage [45].
To the best of the authors’ knowledge, this is the first population study on the sociodemographic correlates of general mental illnesses in a Chinese population. However, the results should be carefully interpreted in view of their limitations, the first of which being the commonly reported limitations of a telephone survey [17, 18]. Second, the use of only six items on stigma-related mental health knowledge from MAKS to assess mental health literacy might have limited the cross-comparison of MAKS scores between studies. However, since this study focused on public stigma, the adopted approach was more effective for capturing stigma-related mental health knowledge. Third, since the survey length was limited to ensure a higher response rate, many potential confounding variables were not captured. Future studies could include sociodemographic factors, such as family structure, marital status, and income, to formulate a better model to explain the sociodemographic characteristics possibly related to the public stigma of mental illness.