Misconceptions, prejudice and social distance towards people with alcohol use disorders in China

doi:10.21203/rs.3.rs-4971967/v1

Purpose:

Research from Western societies indicates pervasive public stigma against people with alcohol use disorders (AUDs). However, there is a lack of knowledge about the interactions between different components of stigma and their contribution to discriminatory behaviour towards individuals with AUDs within the Chinese cultural context. The aim of the present study was therefore to investigate the relationships of (mis-)conceptions, stereotypes, emotional reactions, perceived public stigma and their contribution to the desire for social distance among the Chinese adults.

Methods:

(Mis-)conceptions, stereotypes, emotional responses, willingness to help and avoid, perceived stigma, and the desire for social distance from individuals with AUDs were assessed via a cross-sectional online survey with a sample of 1,100 adults from the Chinese population.

Results:

Three-fourth of the participants recognised AUDs as mental illnesses, though 70% of the sample did not support health insurance coverage for the treatment of AUDs. A stronger desire for social distance was associated with increased perceived public stigma, greater recognition of alcohol use disorders as mental illnesses, heightened perceptions of personal responsibility, increased fear, and more willingness to avoid and withhold help, controlling for age, gender, education, employment, and alcohol consumption.

Conclusions:

To improve social integration for individuals with AUDs in China, culturally tailored anti-stigma programmes are needed to reduce negative attitudes and discriminatory behaviours among the Chinese population.

alcohol use disorders

public stigma

stereotype

discrimination

China

stigma change

Alcohol use disorders (AUDs) are one of the most prevalent mental disorders globally and are associated with high mortality and burden of diseases [1]. In China, the lifetime and 12-month prevalence of any alcohol use disorder was 4.4% and 1.8%, respectively, which was more than that of any drug use disorders [2]. However, many individuals with symptoms consistent with AUDs remain undiagnosed and untreated worldwide [3], including in China, where only 2.4% of individuals with alcohol dependence receive treatment [4]. Recent studies [5-7] indicate that alcohol-related stigma might be one of the most prominent barriers to treatment-seeking for alcohol use disorders.

Myths about AUDs are prevalent and can lead to misconception and stigma, further impeding the willingness of people with AUDs to seek the necessary help and support [8]. Common myths may involve the perception that alcohol use disorders result from personality weakness or character flaws, rather than recognising these disorders as mental illnesses influenced by a complex interplay of biological, psychological, and environmental factors [9]. Some people may believe alcohol-related treatment should not be covered by medical insurance [10]. These oversimplified perspectives can contribute to judgmental attitudes and discourage individuals from seeking help, exacerbating discrimination towards individuals with these conditions and hinder their recovery process.

Public stigma is markedly encountered by people with AUDs and often leads to additional challenges in their lives [11]. Stigma towards AUDs encompasses widely endorsed negative stereotypes, leading to prejudice and discrimination [12]. Common stereotypes about people with AUDs are that they lack self-control, are dangerous and are emotionally unstable [11, 13]. According to the attribution theory of mental illness stigma [14, 15], people who attribute a person’s problems to controllable factors are more likely to be hostile and critical towards this individual. Compared to individuals with psychosis, people with AUDs are judged as much more responsible for their conditions and less worthy of support or care [13]. Prejudice occurs if people endorse these stereotypes and react emotionally. For example, “It is right that people with alcohol use disorders are unreliable and dangerous. I am scared of them” [12]. Discrimination involves unjustified unequal treatment or actions taken towards the stigmatised individuals or groups [16], such as limitations to rental opportunities, employment prospects and interpersonal relationships [17]. Studies among the general population [18, 19] suggested a connection between higher levels of stereotypes and a greater preference for social distance from individuals with AUDs.

Perceived stigma refers to the subjective perception of the stereotypes, prejudice and discrimination held by the majority population [20], which pertains to how stigmatised individuals are viewed and treated by society. It is deeply rooted in public stigma and reflects the anticipated stigmatising attitudes among the general public, where individuals fear being judged, blamed, or socially excluded if they were experiencing alcohol use disorders [21, 22]. Findings from a German national survey [23] suggested a potential association between perceived stigma and the tendency for social distancing from individuals with AUDs. Consequently, perceived stigma may discourage individuals from pursuing the necessary help for their alcohol use problems [24], contribute to social withdrawal to avoid judgement from others [25], and lead individuals to internalise stereotypes, thereby diminishing self-worth [26, 27]. Other types of stigma, such as structural stigma and self-stigma, are also significant factors that can impact individuals with AUDs [13], though these are beyond the scope of this study.

Although drinking alcohol is a widely accepted cultural tradition and crucial for fostering social bonding in China, traditional collectivist culture emphasises morality and self-controlled drinking, stressing maintenance of social order and the avoidance of embarrassment with drunken behaviours [28]. Furthermore, the concept of “saving face” is deeply rooted in Chinese culture [29]. Social harmony and the reputation of the family and community are highly valued. Individuals with AUDs may be viewed as bringing shame not only upon themselves but also upon their families [30]. Feeling ashamed, and fearing being labelled and discriminated against were identified as key factors contributing to reluctance to seek help and social withdrawal among individuals with substance use disorders [30]. These cultural norms, subject to stigma and social marginalization [31], are amplified by the collectivistic nature of Chinese society, where individuals tend to perceive public prejudices as justified [32]. Stigma towards AUDs may therefore be particularly widespread in China.

Few studies conducted among the Chinese population provided initial insights into public stigma and its potential impacts on individuals with AUDs. A community-based study [30] showed that the vast majority of respondents perceived individuals with alcohol addiction as having undesirable characteristics, which could potentially hinder their willingness to seek help. A cross-sectional study [33] found an association between alcohol use problems and experience of unfair treatment in public services. Xiong et al. [34] found that the general public expected occupational restrictions of people with a history of alcohol use problems, particularly in roles requiring high responsibility, such as that of a bus driver. These population-based surveys investigated specific aspects of alcohol-related stigma, however, they did not consider stigma as a multidimensional concept that encompasses various components, including stereotypes, prejudice, and discrimination [12, 13]. Discriminatory behaviour, in particular, is a critical manifestation of stigma, that impacts individuals’ access to treatment, social integration, and overall well-being [17]. The interactions between different components of stigma and their contribution to discriminatory behaviour in the Chinese cultural context remain unclear. Research in this field is needed to inform targeted interventions and address alcohol-related stigma.

The present study therefore aimed to test the hypothesis that a higher level of desire for social distance from individuals with AUDs is independently associated with more (mis-)conceptions, perceived public stigma, stereotypes, and negative emotional reactions among Chinese adults. As female gender, older age, lower education, and unemployment were found to be associated with higher public stigma about mental illness among the Chinese population [35], we controlled age, gender, education, and employment to avoid confounding effects. Additionally, given the association of alcohol consumption and mental health utilisation with alcohol-related stigma [36], we also included these as confounding variables. Findings from the study could help guide the development of targeted interventions to reduce stigma and improve social integration for individuals with AUDs among the Chinese population.

2.1 Design and participants

This cross-sectional online survey involves a convenience sample of Chinese adults. A sample of 1,100 participants, aged 18 and older, engaged in the online survey utilizing the Wenjuanxing platform, which is a professional online survey tool in China and is often compared to Amazon Mechanical Turk in terms of functionality and use. Recruitment of participants was achieved via advertisements on social media platforms, dissemination through community newsletters, and the use of both convenience and snowball sampling methodologies. For the snowball sampling, participants initially recruited through convenience methods were encouraged to refer the study link to other individuals who might potentially meet the study criteria, and all participants were subsequently asked to invite others to participate in the study. Data were collected from March 1st to 15th, 2022.

2.2 Measurements

We provided a description of “alcohol use disorders” in the informed consent to ensure participants had a clear understanding of the term. The term “alcohol use disorders” was consistently used throughout the entire survey.

Adapted from Schomerus et al.’s study [19] on public views towards individuals with AUDs, we used the following empirical questions regarding (mis-)conceptions about AUDs: Whether they think alcohol use disorders are mental illnesses (0=no, 1 = yes); Do they believe that alcohol use disorders are due to a lack of willpower (0 = no, 1 = yes); What do they think is the possible cause of an alcohol use disorder (1 = biogenetic, 2 = psychosocial, 3 = biopsychosocial, 4 = others); Whether they think the treatment for alcohol use disorders should be covered by health insurance (0=no, 1 = yes).

The Attribution Questionnaire (AQ, [14]) was used and adapted to measure stereotypes and emotional responses towards individuals with alcohol use problems. The AQ has been employed in the Chinese population to assess stigmatising attitudes towards individuals with schizophrenia [37] and children with autism [38]. Both adoptions demonstrated robust psychometric properties. In this study, the vignette in the original AQ was modified to depict David, a 32-year-old single male. He is a company employee and currently lives with his parents. Due to his alcohol use disorders, he had been hospitalised for treatment multiple times. After reading the vignette, participants were given eight questions on dangerousness, responsibility, treatment optimism, pity, anger, fear, willingness to help, and avoidance. Items were coded on a 9-point Likert scale from 1 = “none at all” to 9 = “very much” (Cronbach’s alpha = 0.73).

Perceived stigma was measured using a Chinese version of the Perceived Stigma towards People who use Substances [39], which is a cross-cultural validation of the 8-item Perceived Stigma of Addiction Scale [40]. Items were scored from 1 to 4 with higher scores representing stronger agreement with the statements. To specifically measure stigma associated with alcohol use disorders, the term “substance use concerns” was replaced by “alcohol use disorders” in this study (Cronbach’s alpha = 0.79).

The desire for social distance, as a proxy for discriminatory behaviour, was measured by the Link et al.’s Social Distance Scale [20]. This scale has been employed in Chinese samples and has shown good psychometric properties [41]. It comprises 7 items (e. g. “how willing are you to have someone like David as a neighbour?) on a 4-point Likert scale ranging from 0 (definitely willing) to 3 (definitely unwilling), with higher scores representing a greater desire to distance oneself from persons with AUDs (Cronbach’s alpha = 0.90).

Alcohol consumption was assessed using the brief version of the Alcohol Use Disorders Identification Test - Consumption (AUDIT-C, [42]), which included the following three questions: a. How often do you have a drink containing alcohol? b. How many drinks did you have on a typical day when you were drinking in the past year? c. How often did you have 6 or more drinks on one occasion in the past year? The AUDIT-C was scored on a scale ranging from 0 to 12, with higher scores indicating higher levels of alcohol consumption. Risky drinking was defined using an optimal cut-off of ≥5 for males and ≥4 for females in the Chinese population [43].

2.3 Procedure

The study protocol was fully reviewed and approved by the Research & Ethics Committee of Peking University Clinical Medical School, Beijing Huilongguan Hospital, China. Prospective research participants were informed of the study aims and asked to sign an online consent form to participate in the study. Anonymity and confidentiality were ensured throughout the study. The online survey lasted 5 to 10 minutes. It was designed to require participants to complete all questions before submission. Those who did not fully complete the survey were not included in the study. Participants did not receive compensation for their involvement in the survey. To enhance the validity of this survey, time completion checks, IP Address verification, and reverse-coding questions were implemented. Participants who completed the survey too quickly (i.e. less than 2 minutes), provided inconsistent answers on reverse-coded questions, or submitted multiple responses from the same IP address were excluded from the final analysis to ensure data quality.

2.4 Analyses

First, we used descriptive statistics to analyse individual items, determining the extent to which answers to each item are related. Second, Spearman correlations and chi-square tests were used to analyse the correlations between misconceptions, stereotypes, emotional reactions, perceived stigma, and the desire for social distance. As the variable of the potential causes of AUDs contains multiple categories, we treated it as a nominal variable, employing either chi-square test or ANOVA for further correlation analyses. Third, we used multiple linear regression analysis to examine the independent associations of predictor variables with the desire for social distance as the dependent variable, controlling for age, gender, education, employment, alcohol consumption and lifetime mental health service utilisation. As the variable representing the potential causes of alcohol use disorders contains multiple categories, we used dummy independent variables for each non-reference category in the regression model. Multicollinearity was assessed using variance inflation factor (VIF) for each independent variable, with a VIF value 2.5 or above indicating multicollinearity [44]. The data were analysed using Statistical Program for Social Science (SPSS) - version 29. A two-tailed significance of p < 0.05 was used in the analyses. Specifically, for correlation analyses, a more stringent threshold of p < 0.01 was employed to bolster the reliability of the correlation results. A correlation coefficient of 0.10, 0.30, and 0.50 or higher indicates a small, moderate, or large effect size, respectively [45].

Totally, 1,124 participants submitted the survey. Twenty-four participants were excluded because they either completed the survey in less than 2 minutes or provided inconsistent answers on reverse-coded questions. The sample comprised 1,100 participants across 34 province-level administrative regions in China. The vast majority of the participants were from the Han Ethnic group. Nearly 60% of the participants were women. The socio-demographic characteristics of participants are presented in Table 1. In this study, 29.6% of males and 4.9% of females were identified as risky drinkers, which reflects an average level within the general population [46].

Insert Table 1 about here.

Nearly three-quarters of participants recognised AUDs as mental illnesses, though approximately one-third held the belief that individuals with AUDs lacked willpower. Over 60% of participants endorsed a biopsychosocial model of alcohol use disorders. It is noteworthy that nearly 70% of the sample did not support health insurance coverage for alcohol-related treatment (Table 2).

Insert Table 2 about here.

In bivariate relationships, the desire for social distance was markedly associated with a higher level of perceived stigma, moderately associated with more perceived dangerousness, avoidance and higher levels of fear and anger, while there is a weak correlation between the desire for social distance and less willingness to help. Increased perceived dangerousness was highly associated with more perceived responsibility and a higher level of fear. The recognition that AUDs are mental illnesses was slightly associated with a biopsychosocial attribution and greater perceived treatment optimism; however, it was mildly correlated with a greater endorsement of weakened willpower, higher levels of pity and fear, as well as increased perceived stigma and a desire for social distance. Individuals attributing the cause to biogenetics perceived the lowest level of anger, while those with biopsychosocial perspectives were more likely to support health insurance coverage for alcohol-related treatment. More withholding help was associated with higher levels of pity, anger and fear, avoidance, and perceived stigma, while more willingness to help was significantly associated with more perceived dangerousness and treatment optimism. Increased perceived stigma was associated with higher levels of anger and fear, respectively, but neither was associated with pity (Table 3).

Insert Table 3 about here.

We then examined the independent correlations of the desire for social distance using linear regression analysis. After controlling for age, gender, education, employment, lifetime mental health utilisation and alcohol consumption, a greater desire for social distance was independently associated with more recognition of AUDs as mental illnesses, increased perceived responsibility, a higher level of fear, less willingness to help, a greater tendency of avoidance, as well as increased perceived stigma (Table 4). Furthermore, younger people and those who had more alcohol consumption showed less desire for social distance. These factors together explained 40% of the variance in the desire for social distance from individuals with AUDs. All VIF values were less than 2.5, indicating low multicollinearity.

Insert Table 4 about here.

The present study provides initial evidence that a higher level of desire for social distance towards individuals with AUDs is independently associated with increased perceived stigma, stereotypes and negative emotional reactions among Chinese adults. Specifically, consistent with previous findings, stronger perceptions of public stigma, beliefs in personal responsibility for AUDs, higher fear levels, less willingness to help, and a greater tendency to avoid contribute to the desire for social distance.

Contrary to previous findings [13], this study found that a higher level of recognition AUDs as mental illnesses was associated with increased desire for social distance from people with AUDs. In this study, the majority of participants labelled AUDs as mental illnesses and recognised the connection between AUDs and a biopsychosocial model. However, the recognitions coexist with perceptions of lack of willpower, dangerousness, perceived stigma, and a desire for social distance. It implies that alcohol-related stigma may be intertwined with the overall stigma surrounding mental illnesses. The results could help interpret previous findings that despite an increasing knowledge about alcohol use disorders, high levels of public stigma have persisted and, in some cases, worsened [23, 47]. While the recognition of alcohol use disorders as mental illnesses is essential for promoting a comprehensive approach to treatment and support [13, 48], equally critical is the need to address pervasive stigmatised attitudes associated with mental illness.

In China, health insurance plans generally encompass treatment for alcohol use disorders. However, the extent of reimbursement of medical expense varies significantly based on specific insurance plans [49]. Remarkably, a significant majority of the respondents in this study opposed health insurance coverage for alcohol-related treatment, which was associated with perceptions of personal responsibility, unwillingness to help, avoidance and a desire for social distance. This stance could lead to discrimination within the healthcare system and hinder the provision of adequate care [50].

In alignment with previous research [13, 23], heightened perceptions of dangerousness and responsibility were correlated with increased tendencies to avoid, elevated negative emotions such as pity, anger and fear, and a greater desire for social distance. Conversely, higher perceptions of dangerousness and treatment optimism were associated with a greater willingness to help. Safety concerns may drive individuals in collectivistic society, such as China, to engage in helping behaviours that mitigate perceived risks and benefit the collective community [51, 52]. Additionally, an optimistic attitude towards treatment could play a role, as individuals may believe that their assistance can contribute positively to the recovery journey of those with AUDs [53, 54].

However, the public perception of treatment optimism, a proxy of controllability [55], might also create an expectation that individuals should be able to manage their alcohol use problems with available treatments. The failure to meet expectations may result in increased blame and social rejection, especially in Chinese society that emphasise on self-control [6]. Recognising the dual nature of treatment optimism as a double-edged sword in addressing alcohol-related stigma, efforts should extend beyond merely promoting optimism about treatment outcomes to fostering a no-blame perception to reduce stigma and support recovery [56]. Given the significantly low treatment rate for AUDs in China [4], there is a high demand to promote treatment availability and accessibility of AUDs treatment.

Consistent with the reactions observed towards individuals with substance use disorders [6], the negative emotional responses, including pity, fear and anger, were associated with heightened perceived dangerousness, responsibilities and treatment optimism. Pity was associated with more willingness to help, which aligns with previous research indicating that pity might elicit compassion and thus promote supportive behaviour [12]. While pity is often considered as a moral virtue and reflects a compassionate response to someone’s suffering [57], it did not show a significant correlation with perceived stigma or a desire for social distance.

Our findings suggest that perceptions of societal attitudes towards individuals with AUDs could lead to discriminatory behaviour towards the stigmatised group. Stigma emerges as individuals with AUDs are categorised as members of an out-group [16]. This categorisation, especially pronounced in collective societies like China, makes it more likely that people conform to dominant cultural beliefs [58, 59], resulting in discrimination. These results suggest that stigma reduction campaigns in China should aim to address negative attitudes and discriminatory behaviour of the general public [60].

Some limitations to this study need to be considered. First, compared to the general Chinese population, this study had more female, younger participants with higher education levels. Specifically, younger people in this study showed less desire for social distance towards individuals with AUDs, potentially leading to less stigmatising attitudes compared to the general population. Furthermore, the findings may not generalise well to those who are less active online or chose not to participate in this study. Second, there is no causality or potential direction of the associations can be drawn from this cross-sectional study. Third, self-report desire for social distance, rather than observed discriminatory behaviour, was used as a proxy for measuring discrimination. Fourth, a few variables, including (mis-)conception and attributions, were assessed with a single item, providing limited information. This may reduce the sensitivity and statistical power of the analyses. Lastly, social desirability may lead to potential underreporting of stereotypes and the desire for social distance, while leading to an over-reporting of the willingness to help.

Despite these limitations, findings from this study have research and clinical implications for stigma reduction and the improvement of social integration for individuals with AUDs. Highlighting the multifaceted causes of AUDs may help dispel misconceptions and stereotypes, fostering a more supportive and understanding environment for individuals with AUDs. Comprehensive public mental health programmes should address both mental illnesses in general and alcohol use disorders specifically. Without tackling the broader issue of mental illness stigma, educating the public that alcohol use disorders are mental illnesses may inadvertently worsen alcohol-related stigma. Culturally sensitive anti-stigma campaigns need to focus on addressing negative attitudes and discriminatory behaviours by promoting non-blamed causal attributions [61, 62]. Programmes like the Honest, Open, Proud peer-led group programme [63], which support individuals with lived experience to share their recovery stories, can enhance public respect and contribute to stigma change [8]. Future research should develop targeted stigma reduction programmes for various stakeholders, including healthcare professionals, media outlets, policymakers, policemen, employers, and community networks.

In conclusion, this study presents novel findings that highlight heightened perceived public stigma, personal responsibility, fear, more withholding help, and avoidance as significant factors associated with the desire for social distance from individuals with AUDs. The findings underscore the urgent need for targeted stigma reduction programmes that emphasise non-blame attributions and facilitate contact strategies to enhance helping behaviours and social acceptance. Efforts through policy advocacy and population-based anti-stigma campaigns may be critical in fostering a supportive environment for individuals with AUDs.

Acknowledgements

We are grateful to all participants.

Author contributions

Dr Ziyan Xu is responsible for the integrity of the data and the accuracy of data analysis and had full access to all data in the study. Concept and design: Ziyan Xu and Qingyan Yang. Acquisition, analysis, or interpretation of data: All authors. Drafting of the manuscript: Ziyan Xu, Qingyan Yang. Critically revise manuscripts of important intellectual content: Nicolas Rüsch, Patrick W. Corrigan, Kebing Yang, Yajuan Niu, Yunlong Tan. Statistical analysis: Yanxia Xiao, Yanfang Zhou, Ziyan Xu. Obtained funding: Qingyan Yang. Administrative, technical, or material support: Ziyan Xu and Qingyan Yang.

Funding

This paper was supported by Beijing Municipal Administration of Hospitals Incubating Program, PX202307, 2023, and Capital’s Funds for Health Improvement and Research, SF2024-2-2133.

Data Availability

The datasets are available from the corresponding author on reasonable request.

Ethics approval and consent to participate

The study protocol was fully reviewed and approved by the Research & Ethics Committee of Peking University Clinical Medical School, Beijing Huilongguan Hospital, China. All methods were carried out in accordance with the Declaration of Helsinki. Prospective research participants were informed of the study aims and asked to sign an online consent form to participate in the study.

Consent for publication

Not applicable.

Competing interests

None.

Clinical trial number

Not applicable.

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Table 1. Socio-demographic characteristics of participants (N=1,100)

Variable	N (percentage)/M (SD)
Age	39.3 (10.1)
Gender, female	657 (59.7%)
Ethnic groups Han Manchu Korean Hui Mongolian Others	1053 (95.7%) 25 (2.2%) 5 (0.5%) 4 (0.4%) 4 (0.4%) 9 (0.8%)
Education (years) 8-9 10-12 13-16 >16	48 (4.4%) 66 (6.0%) 690 (62.7%) 296 (26.9%)
Married	826 (75.1%)
Unemployed	25 (2.3%)
Alcohol consumption (0-12)	2.3 (2.6)
Any mental health service use, lifetime	140 (12.7%)

Table 2. Descriptive Statistics (N=1,100)

Variable	N (Percentage)/ M ± SD (Range)
AUDs ^a are mental illnesses (yes)	820 (74.5%)
AUDs are due to a lack of willpower (yes)	345 (31.4%)
Potential causes of AUDs Bio-psycho-social Psychosocial Biological Others	700 (63.6%) 235 (21.4%) 16 (1.5%) 149 (13.5%)
Supporting health insurance coverage (yes)	338 (30.7%)
Attributions ^b Dangerousness	7.28 ± 1.87 (1-9)
Responsibility	7.63 ± 1.66 (1-9)
Treatability	7.04 ± 1.98 (1-9)
Willingness to help	5.46 ± 2.36 (1-9)
Avoidance	5.35 ± 2.43 (1-9)
Pity	5.87 ± 2.75 (1-9)
Anger	5.84 ± 2.52 (1-9)
Fear	6.32 ± 2.28 (1-9)
Perceived stigma ^b	23.96 ± 4.39 (9-36)
Desire for social distance ^b	24.68 ± 3.69 (7-28)

^a AUD = Alcohol use disorders; ^b A higher score indicates a higher level of the measured variables

Table 3. Correlations between misconceptions, stereotypes, emotional reactions, perceived stigma and the desire for social distance (* p<0.01; ** p<0.001)

		1	2	3	4	5	6	7	8	9	10	11	12	13
1	AUDs^a are mental illnesses
2	Lack of willpower	0.20^**
3	Potential causes of AUDs^{a, b}	0.12^**c	-0.05
4	Supporting health insurance coverage	0.04	-0.03	0.10^*c
5	Dangerousness	0.07	0.05	0.02	-0.02
6	Responsibility	0.05	0.08^*	-0.02	-0.10^*	0.53^**
7	Treatability	0.18^**	0.05	-0.02	0.001	0.45^**	0.40^**
8	Willingness to Help	0.05	0.01	0.07	0.08^*	0.17^**	0.07	0.32^**
9	Avoidance	0.04	0.12^**	-0.04	-0.12^**	0.26^**	0.27^**	0.11^**	-0.22^**
10	Pity	0.09^*	0.02	0.04	0.04	0.32^**	0.19^**	0.26^**	0.29^**	0.03
11	Anger	0.03	0.14^**	0.09^*d	-0.06	0.42^**	0.40^**	0.31^**	0.29^**	0.27^**	0.29^**
12	Fear	0.07^*	0.12^**	0.04	-0.02	0.64^**	0.48^**	0.32^**	0.11^**	0.37^**	0.27^**	0.54^**
13	Perceived stigma	0.14^**	0.12^**	-0.05	-0.002	0.06	0.10^*	0.07	-0.11^**	0.20^**	-0.02	0.10^*	0.10^*
14	Desire for social distance	0.12^**	0.14^**	-0.02	-0.08^*	0.32^**	0.32^**	0.19^**	-0.13^**	0.41^**	0.05	0.29^**	0.38^**	0.49^**

^aAUDs = Alcohol use disorders.

^b It is treated as a nominal variable with multiple categories (biogenetic, psychosocial, biopsychosoical and other causal beliefs).

^c It is positively associated with biopsychosocial perspectives.

^d A biogenetical perspective was associated with the lowest level of anger, followed by psychosocial and then biopsychosocial perspectives.

Table 4. Linear regression analysis on the desire for social distance, controlling for age, gender, education, employment, alcohol consumption and lifetime mental health service us (Adjusted R²=0.41)

Independent variables	B^*	SE^{c* d}Error	Beta^#	p	95% CI^d
AUD^a is a mental illness (0=no, 1=yes)	0.60	0.26	0.07	0.02	0.09 – 1.11
AUDs are due to a lack of willpower (0=no, 1=yes)	0.30	0.23	0.04	0.18	-0.14 – 0.74
Potential causes of AUDs^b	-0.35	0.29	-0.04	0.23	-0.92 – 0.22
Supporting health insurance coverage (0=yes, 1=no)	0.11	0.22	0.01	0.60	0.54 – -0.31
Dangerousness	0.12	0.07	0.06	0.09	-0.02 – 0.27
Responsibility	0.20	0.07	0.09	0.006	0.06 – 0.35
Treatability	0.05	0.06	0.03	0.44	-0.07 – 0.17
Pity	-0.05	0.04	-0.04	0.22	-0.13 – 0.03
Anger	0.03	0.05	0.02	0.59	-0.07 – 0.13
Fear	0.20	0.06	0.13	0.002	0.08 – 0.32
Willingness to Help	-0.15	0.05	-0.09	0.004	-0.25 – -0.05
Avoidance	0.27	0.05	0.18	<0.001	0.18 – 0.36
Perceived stigma	0.34	0.03	0.37	<0.001	0.29 – 0.39
Age	0.03	0.01	0.09	0.001	0.01 – 0.05
Gender (0=male, 1=female)	-0.17	0.24	-0.02	0.49	-0.64 – 0.30
Education (years)	-0.08	0.09	0.03	0.38	0.11 – -0.28
Employment (0=no, 1=yes)	-0.87	0.78	0.03	0.27	0.66 – -2.39
Any mental health service uses, lifetime (0=no, 1=yes)	-0.18	0.29	-0.02	0.55	-0.75 – 0.40
Alcohol consumption	-0.22	0.05	-0.15	<0.001	-0.31 – -0.13

^aAUD = Alcohol use disorder. ^breference category = biopsychosocial model. ^cSE = Standard Error.

^dCI = Confidence Interval. ^* Unstandardised coefficient. ^# Standardised coefficient.

No competing interests reported.

Misconceptions, prejudice and social distance towards people with alcohol use disorders in China

Status:

Version 1

Abstract

1. Introduction

2. Methods

3. Results

4. Discussion

Declarations

References

Tables

Additional Declarations

Status:

Version 1