Archives of Psychiatric Nursing 32 (2018) 802–808

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Archives of Psychiatric Nursing

journal homepage: www.elsevier.com/locate/apnu

Stigma towards people with mental disorders: Perspectives of nursing T

students
⁎
Ellaisha Samari , Esmond Seow, Boon Yiang Chua, Hui Lin Ong, Edimansyah Abdin,
Siow Ann Chong, Mythily Subramaniam
Research Division, Institute of Mental Health, Singapore

Stigma towards people with mental disorders is highly prevalent (Happell, 2005). Harbouring negative views towards people with
and often leads to negative impact on their lives (Alonso et al., 2008; mental disorders may thus be challenging as these would influence the
Corrigan and Watson, 2006). According to The World Health way nurses view their patients and the nature of their work itself
Organization (2001), stigma signifies a ‘mark of shame, disgrace, or (Enarsson, Sandman, and Hellzen, 2007), which may not only affect
disapproval’. The negative consequences of stigmatizing attitudes in- their role as an advocate in reducing stigma, but also hinder the de-
clude ‘being rejected, discriminated against and excluded from parti- velopment of therapeutic relationship with patients (Kameg, Mitchell,
cipating in a number of different areas of society’. Furthermore, being Clochesy, Howard, and Suresky, 2009).
stigmatized not only affects the psychological well-being and develop- Therefore, nursing education and placements carry great responsi-
ment of people with mental disorders, but also acts as a significant bilities in shaping the attitudes that are held by nursing students to-
barrier to seeking, accessing and adherence to treatment (Link and wards people with mental disorders. By providing enough depth and
Phelan, 2006). exposure to theoretical and practical knowledge, a more positive atti-
Prior research studies have generally revealed continued mis- tude towards mental health nursing could be expected. This would
conceptions about mental disorders amongst various populations. In subsequently prepare them for a nursing profession in the mental health
their review of population studies, Angermeyer and Dietrich (2006) field (Happell, 1999). Whether nursing students eventually pursue a
found that a significant proportion of the public were unable to re- career in psychiatric nursing or other areas of nursing, they would most
cognize specific mental disorders and their respective causes. They also likely encounter patients with mental disorders. Being on the practice
perceived people with mental disorders as unpredictable and dan- front, it is thus imperative that nurses have a positive attitude towards
gerous. These perceptions contributed to increasing desire to distance patients who have mental disorders. Furthermore, discovering the ex-
themselves from people with mental disorders. Notably, research has tent of stigma is fundamental to gaining insights into the current ste-
also shown the presence of a hierarchy of stigma within mental dis- reotypes that could subsequently be addressed and further clarified
orders diagnoses where more stigmatizing attitudes are directed to- during nursing education and placements. Ultimately, an understanding
wards people with schizophrenia as compared to other mental disorders of nursing students' attitudes would aid in shaping nursing education.
such as mood or anxiety disorders (Griffiths et al., 2006). Singapore has twenty-one accredited nursing programmes as of
Stigmatizing attitudes towards people with mental disorders are not December 2015 (Singapore Nursing Board, 2016), including degree in
restricted to only uninformed members of the general public. nursing, diploma in nursing, and others. Mental health nursing curri-
Healthcare professionals also endorse stereotypical beliefs about people culum differs across programmes based on the objectives they have set
with mental disorders (Jorm et al., 1999; Ross and Goldner, 2009). out for their students. Nonetheless, nursing students across these pro-
These stigmatizing attitudes amongst mental healthcare professionals grammes are required to complete a mental health module and subse-
can act as barriers to those seeking treatment and hence need to be quently undergo a clinical placement in a mental health facility. Nur-
broken down. Essentially, healthcare professionals, especially nurses, sing students typically undergo their placements in a tertiary
play a key role in the mental healthcare system (Harborne and Jones, psychiatric hospital for a span of two weeks in an inpatient ward setting
2008). Being on the frontline of healthcare, they are responsible for the – acute care or long stay ward.
bulk of direct care for patients (Baker, Richards, and Campbell, 2005) While a recent population-wide study explored the extent of stig-
and have a profound effect on the therapeutic relationship as well as matizing attitudes towards people with mental disorders in Singapore
treatment outcomes of patients with whom they interact. Furthermore, (Subramaniam et al., 2016), there is no previous study that compared
given their high contact and experience with patients, nurses are well attitudes amongst nursing students across different types of mental
positioned to ameliorate stigmatizing attitudes amongst the public disorders and examined the extent of stigma amongst nursing students

⁎
Corresponding author at: Research Division, Institute of Mental Health, Buangkok Green Medical Park, 10 Buangkok View, 539747, Singapore.
E-mail address: [email protected] (E. Samari).

https://doi.org/10.1016/j.apnu.2018.06.003
Received 5 June 2017; Received in revised form 19 March 2018; Accepted 2 June 2018
0883-9417/ © 2018 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/BY-NC-ND/4.0/).
E. Samari et al. Archives of Psychiatric Nursing 32 (2018) 802–808

in Singapore towards people with mental disorders. Furthermore, a 3 = neither agree nor disagree, 4 = disagree, 5 = strongly disagree).
limited number of studies have examined nursing students' attitudes Higher scores suggest a more stigmatizing attitude. Cronbach's α for the
towards people with mental disorders across various types of mental personal stigma scale was 0.647.
disorders in Asia. This study could thus contribute to the dearth of this The Social Distance Scale (SDS) (Link, Phelan, Bresnahan, Stueve,
research in this region. and Pescosolido, 1999) was used to assess respondents' self-reported
Using a vignette approach, the present study aims to (i) examine the willingness to have contact with the person depicted in the vignette.
extent of overall stigma towards people with mental disorders (de- Specifically, respondents rated their willingness to 1. move next door to
pression, obsessive compulsive disorder (OCD), schizophrenia, de- the person in the vignette; 2. spend an evening socialising with the
mentia and alcohol abuse) as well as to (ii) examine factors that cor- person; 3. make friends with the person; 4. work closely on a job with
relate with the stigma dimensions amongst the nursing student the person; and 5. have the person marry into the family. Ratings for
population in Singapore. each item were measured on a 4-point scale (1 = definitely unwilling,
2 = probably unwilling, 3 = probably willing, 4 = definitely willing).
Methodology Lower scores suggest greater social distance desired by respondents.
Cronbach's α for this scale was 0.827.
Design and sample A similar vignette-based approach and measurement tool was used
in a previous population-based study conducted by Subramaniam et al.
In this cross-sectional study, an online web survey tool (2016) in Singapore. Factor analysis done on these measurement tools
QuestionPro® was used to collect data from a sample of nursing stu- suggested a two-factor structure of the depression stigma scale (‘weak-
dents in Singapore. Ethical approval was granted by the National not-sick’ and ‘dangerous-unreliable’), consistent with a study done by
Healthcare Group Domain Specific Review Board in Singapore. The Yap, Mackinnon, Reavley, and Jorm (2014), and a one-factor structure
target population included students from four public nursing institu- for social distance scale (‘social distance’). The first dimension ‘weak
tions in Singapore. Once permissions were granted from the corre- not sick’, comprised three items (PS1–PS3). These items describe the
sponding institutions, mass email invitations were sent to these nursing problem which the person depicted in the vignette is experiencing as a
students to invite them to partake in the study. Enclosed in the email form of personal weakness that is within his/her control as opposed to
was a link that directed potential participants to an online portal where it being a medical condition. The subsequent four items (PS4, PS5, PS6
screening questions were asked to assess their suitability for the study. and PS8) formed the second dimension ‘dangerous/unpredictable’.
These included participants' course of study, nationality, academic year These items describe the person depicted in the vignette as one who is
and institution. Participation quota was based on institutions and aca- dangerous and whom is best avoided. The third dimension ‘social dis-
demic years. In order to be eligible for the study, participants had to be tance’ comprised all the five items from the social distance scale
nursing students who were enrolled in a public nursing institution in (SD1–SD5) which loaded strongly into a single factor. Following the
Singapore during the recruitment period (April 2016 to July 2016) and aforementioned population-based study, the total score for each of the
be a Singapore citizen or permanent resident. Those who did not meet three dimensions were calculated by summing all the items in each
the inclusion criteria received an automatic email notifying them of dimension. For ‘dangerous/unpredictable’ dimension, item (PS7) ‘if I
their ineligibility for this study. Those who met the inclusion criteria had a problem like [vignette] I would not tell anyone’ was excluded
were directed to the online consent form. Participation was voluntary. from the calculation. All 5 items from the ‘social distance’ factor were
By clicking on the ‘agree’ button, participants indicated their will- reversed coded before they were summed together. Higher scores for
ingness to participate in this study. Upon completion, participants were each dimension represent more stigmatizing attitudes towards mental
reimbursed with an inconvenience fee. illness.
Participants were randomly assigned to one of five vignettes de-
scribing a person with a mental disorder - (i) alcohol abuse, (ii) de-
mentia, (iii) depression, (iv) OCD or (v) schizophrenia. Vignettes were Statistical analyses
adapted from those used in prior studies – ‘depression’ and ‘schizo-
phrenia’ vignettes were adapted from Jorm et al. (1997) while ‘alcohol IBM SPSS Statistics Version 23 was used to conduct all statistical
abuse’, ‘dementia’ and ‘OCD’ vignettes were adapted from analyses in this study. Mean and standard error of mean were calcu-
Subramaniam et al. (2016). Participants were then asked to indicate lated for continuous variables while frequencies and percentages were
their attitudes towards the person described in the assigned vignette calculated for categorical variables. For descriptive analyses, items on
using two different scales – the personal and perceived scale of De- the personal and perceived stigma scale were recoded and grouped into
pression Stigma Scale (DSS) (Griffiths et al. 2004) and the ‘Social Dis- three categories; agree, neither agree nor disagree and agree (items
tance Scale’ (SDS) (Link, Phelan, Bresnahan, Stueve, and Pescosolido, ‘agree’ and ‘strongly agree’ were combined into ‘agree’ while ‘disagree’
1999). and ‘strongly disagree’ were combined into ‘disagree’), while items on
the social distance scale were recoded as binary responses; willing and
Instruments unwilling (items ‘definitely willing’ and ‘willing’ were combined into
‘willing’ and ‘definitely unwilling’ and ‘unwilling’ were combined into
The Depression Stigma Scale (DSS) (Griffiths, Christensen, Jorm, ‘unwilling’).
Evans, and Groves, 2004) which has two subscales (personal and per- T-tests and one-way ANOVA tests were conducted to identify dif-
ceived stigma) was developed to measure stigma towards people with ferences in mean scores on all three stigma dimensions across these
mental disorders. Each subscale has nine items and asks respondents variables: gender, ethnicity, education level, monthly household in-
about their own (personal stigma scale) or their beliefs about others' come, clinical placement experience, lectures on psychiatry, type of
attitudes (perceived stigma scale) towards the person who was de- vignette administered and whether family or friends ever had problems
scribed as having depression in the vignette. Although originally de- similar to the person described in the vignette. Multivariate linear re-
signed to measure stigma towards depression, the scale can also be used gressions were also conducted to examine the associations of the
to measure stigma towards other disorders as described in the relevant aforementioned variables with each of the stigma dimensions towards
vignettes. Eight out of the nine items of the personal stigma scale were people with mental disorders. Listwise deletion was used to handle
used in this study, excluding one item “I would not vote for a politician missing data. All statistically significant results were reported at
if I knew they had a mental disorder”. Ratings for each item were p < 0.05.
measured on a 5-point Likert scale (1 = strongly agree, 2 = agree,

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E. Samari et al. Archives of Psychiatric Nursing 32 (2018) 802–808

Table 1 Table 2b
Sociodemographic characteristics of the study sample Item endorsement of the Social Distance Scale – social distance.
n % ‘Social distance’ dimension Unwilling Willing

Age Mean = 20.1 years n % n %

SD = 3.1
Gender Male 83 16.6 SD1. How willing would you be to move next door to 126 25.2 374 74.8
Female 417 83.4 X?
Ethnicity Chinese 287 57.4 SD2. How willing would you be to spend an evening 137 27.4 363 72.6
Malay 134 26.8 with X?
Indian 60 12.0 SD3. How willing would you be to make friends with 59 11.8 441 88.2
Others 19 3.8 X?
Current education Degree 100 20.0 SD4. How willing would you be to have X start 151 30.2 349 69.8
Diploma and others 400 80.0 working closely with you on a job?
Average monthly household income per Below SGD2000 158 31.6 SD5. How willing would you be to have X marry into 330 66.0 170 34.0
capita over the past 1 year SGD2000 - 5999 248 49.6 your family?
SGD6000 and 94 18.8
above
Clinical placement experience Yes 303 60.6
more participants agreed that ‘people with a problem like X’s are un-
No 197 39.4
Lectures Yes 424 84.8
predictable’ (PS6–47.0%). However, participants were less likely to
No 76 15.2 agree that the person described in the vignette was dangerous to others
Vignette Type Depression 100 20.0 (PS4–18.6%) and should be best avoided in order to avoid contracting
OCD 100 20.0 the same disorder (PS5–5%). They were also less likely to agree that
Alcohol abuse 100 20.0
they would not tell someone if they had a similar problem (PS7–21.4%)
Dementia 100 20.0
Schizophrenia 100 20.0 and would not employ someone with such a problem (PS8–18.4%).
Family or close circle of friends ever had Yes 125 25.0
problems similar to person described No 375 75.0 ‘Social distance’ dimension and its pattern of endorsement
in the vignette

Table 2b reports the endorsement of stigmatizing statements in the

Results ‘social distance’ dimension. It reports the percentage of participants
who were either ‘willing’ or ‘unwilling’ to make social contact with the
500 nursing students (83 male, 417 female) aged between 16 and person described in the vignette for each item on the scale. In general, a
35 years old (M = 20.1, SD = 3.1) completed the study. Table 1 pre- larger percentage of participants were willing to have social contact by
sents the sociodemographic characteristics of the participants. saying that they were willing to: move next door to (SD1–74.8%), spend
an evening with (SD2–72.6%), make friends with (SD3–88.2%) and
work closely on a job with someone who has a mental disorder
‘Weak not sick’ dimension and its pattern of endorsement (SD4–69.8%). However, the social interaction that participants were
most unwilling to engage in was having the person with a mental dis-
As seen in Table 2a, percentage difference between participants who order marry into their family (SD5–66% were unwilling).
‘agree’ and ‘disagree’ to each item within the ‘weak not sick’ dimension
shows that a larger number of participants endorsed stigmatizing atti-
Stigma dimensions
tudes on items ‘PS1’ as compared to items ‘PS2’ and ‘PS3’. Specifically,
more participants agreed that ‘people with a problem like X could get
Descriptive values of the three established dimensions of stigma –
better if they wanted to (PS1–77.2%). However, participants were less
‘weak not sick’, ‘dangerous/unpredictable’ and ‘social distance’ – across
likely to agree that ‘a problem like X is a sign of personal weakness
sociodemographic groups are reported in Table 3. Higher mean scores
(PS2–23%) and ‘X’s problem is not a real medical illness' (PS3–17.2%).
denote higher level of stigma for all three dimensions.
Multivariate linear regression analyses reported in Table 4 shows
‘Dangerous/unpredictable’ dimension and its pattern of endorsement the correlates of variables predicting the three factors of stigma men-
tioned above. Participants who were Malay (β = 0.578, p < 0.05),
Table 2a also shows that a larger number of participants endorsed received the ‘depression’ (β = 0.597, p < 0.05) or ‘alcohol abuse’
stigmatizing attitudes on items ‘PS6’ as compared to the rest of the (β = 0.759, p < 0.05) vignette were significantly associated with
items within the ‘dangerous/unpredictable’ dimension. Specifically, higher ‘weak not sick’ scores while those pursuing a degree in nursing

Table 2a
Item endorsement of the Depression Stigma Scale – personal stigma.
Disagree Neither agree nor disagree Agree

n % n % n %

‘Weak not sick’ dimension

PS1. People with a problem like X could get better if they wanted to. 47 9.4 67 13.4 386 77.2
PS2. A problem like X's is a sign of personal weakness. 219 43.8 166 33.2 115 23.0
PS3. X's problem is not a real medical illness. 282 56.4 132 26.4 86 17.2

‘Dangerous/unpredictable’ dimension
PS4. People with a problem like X's are dangerous to others. 261 52.2 146 29.2 93 18.6
PS5. It is best to avoid people with a problem like X's so that you don't also get this problem. 412 82.4 63 12.6 25 5.0
PS6. People with a problem like X's are unpredictable. 107 21.4 158 31.6 235 47.0
PS7. If I had a problem like X's I would not tell anyone. 232 46.4 161 32.2 107 21.4
PS8. I would not employ someone if I knew they had a problem like X. 227 45.4 181 36.2 92 18.4

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Table 3
Descriptive statistics of stigma dimensions by sociodemographic factors.
Weak not sick Dangerous/unpredictable Social distance

a a
Mean S.E. p value Mean S.E. p value Meana S.E. p value

Overall 9.010 0.096 10.320 0.119 11.226 0.117

Gender
Male 8.840 0.220 0.452 10.482 0.319 0.545 10.759 0.291 0.075
Female 9.040 0.110 10.288 0.128 11.319 0.127
Ethnicity
Chinese 8.690 0.126 0.000 10.216 0.161 0.342 11.307 0.160 0.082
Malay 9.679 0.171 10.634 0.214 10.873 0.202
Indian 9.267 0.286 10.017 0.354 11.250 0.351
Others 8.211 0.527 10.632 0.636 12.421 0.520
Average monthly household income per capita over the past 1 year
Below SGD2000 9.171 0.169 0.025 10.304 0.216 0.351 10.867 0.201 0.058
SGD2000–5999 9.105 0.130 10.456 0.166 11.492 0.170
SGD6000 and above 8.468 0.247 9.989 0.280 11.128 0.265
Current education
Degree 7.920 0.242 0.000 9.860 0.244 0.053 11.070 0.241 0.506
Diploma and others 9.277 0.100 10.435 0.135 11.265 0.133
Clinical placement experience
Yes 9.109 0.121 0.185 10.528 0.160 0.030 11.436 0.150 0.026
No 8.848 0.158 10.000 0.173 10.904 0.185
Attended psychiatry lecture
Yes 9.045 0.099 0.342 10.276 0.130 0.383 11.210 0.125 0.746
No 8.789 0.312 10.566 0.300 11.316 0.325
Vignette type
Depression 9.200 0.234 0.015 9.680 0.229 0.000 10.710 0.270 0.000
OCD 8.860 0.195 9.000 0.246 10.530 0.246
Alcohol abuse 9.560 0.206 11.270 0.287 11.760 0.239
Dementia 8.610 0.233 10.700 0.247 11.030 0.252
Schizophrenia 8.800 0.196 10.950 0.254 12.100 0.269
Family or close circle of friends ever had problems similar to person described in the vignette
Yes 8.584 0.222 0.011 9.808 0.238 0.013 10.304 0.243 0.000
No 9.147 0.104 10.491 0.137 11.533 0.130

a
Higher mean scores denote higher level of stigma.

(β = −1.175, p < 0.05) and those whose family or close circle of stigmatizing attitudes for every item in the ‘weak not sick’ dimension as
friends ever had problems similar to person described in the vignette compared to Singapore's general population (PS1–89.4%; PS2–50.8%;
(β = −0.457, p < 0.05) were significantly associated with lower PS3–38.5%), based on percentage of those who ‘agree’ to each item in
‘weak not sick’ scores. Participants pursuing a degree in nursing the scale. In the ‘dangerous/unpredictable’ dimension, the nursing
(β = −0.639, p < 0.05) and those who had attended psychiatry lec- student population (PS4–18.6%; PS5–5.0%; PS6–47.0%; PS7–21.4%;
tures (β = −0.916, p < 0.05) had lower ‘dangerous/unpredictable PS8–18.4%) were less likely to endorse stigmatizing attitudes on all
scores’. Male participants (β = −0.711 p < 0.05), those who received items except ‘PS7 (If I had a problem like X's I would not tell anyone) as
the ‘dementia’ vignette (β = −0.817, p < 0.05) and those whose fa- compared to Singapore's general population (PS4–35.7%; PS5–10.6%;
mily or close circle of friends ever had problems similar to the person PS6–62.5%; PS7–21.4%; PS8–45.3%). In the ‘social distance’ dimension
described in the vignette (β = −1.003, p < 0.05) were significantly (Supplementary Table 2), the nursing student population (SD1–25.2%;
associated with lower social distance scores. Interestingly, participants SD2–27.4%; SD3–11.8%; SD4–30.2%; SD5–66.0%) were more willing
who were presented with either the ‘depression’ (β = −1.072, to have social contact with people who have a mental disorder as
p < 0.05; β = −1.019, p < 0.05) or ‘OCD’ vignette (β = −1.879, compared to Singapore's general population (SD1–32.4%; SD2–22.4%;
p < 0.05; β = −1.495, p < 0.05) were associated with lower ‘dan- SD3–18.2%; SD4–42.8%; SD5–70.2%), with the exception of item ‘SD2
gerous/unpredictable scores’ and ‘social distance’ scores, participants (How willing would you be to spend an evening with X?)’.
who had attended clinical placements (β = 0.822, p < 0.05; While previous studies have shown that nursing students hold di-
β = 0.730, p < 0.05) were associated with significantly higher dan- verse views and attitudes about mental disorders, they were found to be
gerous/unpredictable and social distance scores. generally positive in various studies such as those conducted in New
Zealand (Surgenor, Dunn, and Horn, 2005), Hong Kong (Callaghan,
Discussion Shan, Yu, Ching, and Kwan, 1997) and across several countries in
Europe (Chambers et al., 2010). However, results of some studies are
The main purpose of this study was to examine the extent of overall contrary to current results. For example, a study in Sweden found that
stigma towards people with mental disorders (depression, OCD, schi- nursing students did not demonstrate a positive attitude towards per-
zophrenia, dementia and alcohol abuse) and factors that were sig- sons with mental disorders as compared to their general population
nificantly correlated with the stigma dimensions amongst the nursing (Ewalds-Kvist, Högberg, and Lützén, 2012).
student population in Singapore. In general, results from this study are Taking into consideration participants' age range of 16 to 35 years in
encouraging as it showed evidence of a relatively low endorsement of this study, it could perhaps reflect a growing knowledge and under-
stigmatizing attitudes towards people with mental disorders within the standing about mental disorders amongst the younger age group.
nursing student population. In fact, when compared against the larger Similarly, previous research studies showed that people from the
Singapore population (Subramaniam et al., 2016) as shown in supple- younger age group tend to be less stigmatizing when compared to the
mentary table 1, the nursing student population in Singapore ones from the older age groups (Chong et al., 2007; Hayward and
(PS1–77.2%; PS2–23.0%; PS3–17.2%) were less likely to endorse Bright, 1997; Subramaniam et al., 2016). Furthermore, as nursing

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Table 4
Multivariate linear regression analyses for variables predicting stigma dimensions.
Weak not sick Dangerous/unpredictable Social distance

β 95% confidence interval p value β 95% confidence interval p value β 95% confidence interval p value

Gender
Male −0.206 −0.698 0.286 0.412 0.092 −0.510 0.694 0.764 −0.711 −1.307 −0.115 0.020
Female Ref Ref Ref
Ethnicity
Malay 0.578 0.131 1.025 0.011 0.221 −0.326 0.769 0.428 −0.525 −1.067 0.017 0.058
Indian 0.305 −0.289 0.899 0.313 −0.560 −1.287 0.167 0.131 −0.356 −1.076 0.363 0.331
Others −0.636 −1.596 0.323 0.193 0.338 −0.837 1.513 0.572 1.158 −0.005 2.321 0.051
Chinese Ref Ref Ref
Average monthly household
income per capita over the
past 1 year
Below SGD2000 0.166 −0.380 0.711 0.551 0.086 −0.582 0.754 0.801 −0.367 −1.028 0.294 0.276
SGD2000–5999 0.167 −0.335 0.669 0.513 0.345 −0.270 0.960 0.271 0.287 −0.322 0.895 0.355
SGD6000 and above Ref Ref Ref
Current education
Degree −1.175 −1.676 −0.674 0.000 −0.639 −1.253 −0.026 0.041 −0.452 −1.058 0.155 0.144
Diploma and others Ref Ref Ref
Clinical placement experience
Yes 0.404 −0.036 0.845 0.072 0.822 0.283 1.361 0.003 0.730 0.197 1.264 0.007
No Ref Ref Ref
Attended psychiatry lecture
Yes −0.159 −0.756 0.437 0.600 −0.916 −1.646 −0.186 0.014 −0.719 −1.442 0.004 0.051
No Ref Ref Ref
Vignette type
Depression 0.597 0.010 1.184 0.046 −1.072 −1.790 −0.354 0.004 −1.019 −1.730 −0.308 0.005
OCD 0.107 −0.465 0.678 0.714 −1.879 −2.579 −1.180 0.000 −1.495 −2.187 −0.803 0.000
Alcohol abuse 0.759 0.186 1.331 0.010 0.308 −0.394 1.009 0.389 −0.272 −0.966 0.422 0.442
Dementia −0.027 −0.610 0.555 0.927 −0.032 −0.745 0.681 0.930 −0.817 −1.523 −0.112 0.023
Schizophrenia Ref Ref Ref
Family or close circle of friends
ever had problems similar
to person described in the
vignette
Yes −0.457 −0.889 −0.025 0.038 −0.521 −1.050 0.008 0.054 −1.003 −1.526 −0.479 0.000
No Ref Ref Ref

students, they are probably more familiar and knowledgeable about lead to changes in attitudes, beliefs and stigma towards them. A lit-
treatment, causes and outcomes of mental disorders, which may have erature review done by Couture and Penn (2003) found both personal
led to less stigmatizing attitudes towards people with mental disorders. and professional contact to be associated with positive attitudes to
In fact, previous research studies reported that familiarity with mental mental disorders. In a similar vein, research studies comparing the level
disorders and people suffering from them was associated with positive of stigma amongst nursing students before and after psychiatric clinical
attitudes (Hayward and Bright, 1997; Angermeyer and Dietrich, 2006). placements found that clinical placements helped to foster positive at-
This would have contributed to the development of more informed titudes towards mental health nursing (Happell and Gaskin, 2012) and
perspectives of people with mental disorders which may have decreased that this platform facilitated the demystification of preconceived ideas
the stigma surrounding mental disorders. Nevertheless, looking at the and stereotypes that students have towards mental disorders (Schafer,
level of knowledge alone would be insufficient to form an under- Wood, and Williams, 2011). Other studies however found no support
standing of nursing students' attitudes towards people with mental for the contact hypothesis. A study amongst nursing students in Hong
disorders. It is likely that knowledge has an intricate relationship with Kong showed that previous contact with people with mental disorders
other sociodemographic characteristics of individuals. In fact, a study had no significant effect on students' attitudes towards people with
by Griffiths, Christensen, and Jorm (2008) found that that depression mental disorders (Callaghan, Shan, Yu, Ching, and Kwan, 1997). An-
literacy was inversely related to stigma after controlling for other so- other study done by Gras et al. (2014) which investigated stigmatizing
ciodemographic variables including age and education level. Further attitudes amongst mental healthcare professionals also found that
research exploring the relationship of sociodemographic characteristics personal and work experience in mental health did not influence stig-
with knowledge and subsequently attitudes, would be beneficial in matizing attitudes towards people with mental disorders. However,
enriching the literature. results from our study may perhaps indicate that negative attitudes
We found that those who had clinical placement experience (pro- towards people with mental disorders were developed during the
fessional contact) had significantly more stigmatizing attitudes towards clinical placement experience or that negative preconceptions held to-
people with mental disorders on two stigma dimensions: ‘dangerous/ wards people with mental disorders prior to clinical placements were
unpredictable’ and ‘social distance’. This showed that these nursing hardened during contact with them. A possible explanation for either
students were more likely to perceive people with mental disorders as interpretation could be due to exposure to situations that nursing stu-
dangerous and unpredictable, and wanting greater social distance from dents were not fully prepared to face or deal with such as in witnessing
them. Prior studies have shown mixed evidence of how contact ex- psychotic or violent behaviours from patients, which Fisher's (2002)
perience, including having attended clinical placement affects attitudes study found to contribute to negative experiences reported by health-
towards people with mental disorders. According to Allport's (1954) care students.
contact hypothesis, interaction with people from a different group can Having a family member or a close friend (close contact) who had

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similar problems as the one in the vignette, was significantly associated Nursing education implications
with lower stigmatizing attitudes on two stigma dimensions: ‘weak not
sick’ and ‘social distance’. Having a family member or close friend with Considering the negative correlation between close contact of
a mental disorder may result in increased feelings of empathy and people with mental disorders and stigma in this study, psychiatric
greater knowledge of the mental disorder itself. Furthermore, associa- nursing curriculum could focus on creating a closer contact experience
tions with persons with mental disorders by family ties or friendships between nursing students and people with mental disorders prior to
may have resulted in similar experience of the negative consequences of clinical placements. Additionally, nursing schools could also review
mental disorders stigma (Corrigan, Morris, Michaels, Rafacz, and their preparation methods for students attending clinical placements,
Rϋsch, 2012) which could have led to greater empathy and hence less and include managing students' expectations of the institution they
stigmatizing attitudes. would be attending at for their clinical placements and types of patients
Participants who were presented with the ‘depression’ and ‘alcohol they would be interacting with. This study also showed that stigma
abuse’ vignette were significantly more likely to perceive the person in towards mental disorders varies based on its type. Possibly, nursing
the vignette as ‘weak not sick’ in comparison to those presented with schools could effectively reduce stigma towards people with mental
the ‘schizophrenia’ vignette. Angermeyer, Matschinger, and Schomerus disorders by addressing identified misconceptions of people with each
(2013) found that public attitudes towards people will mental disorders mental disorder i.e. people with depression or people with schizo-
are disorder specific and there is an increasing difference between at- phrenia in depth rather than addressing it as a single concept i.e. people
titudes towards schizophrenia and other mental disorders including with mental disorders.
their perceived causal attributions. Schizophrenia was more likely to be
attributed to brain disease while depression to stress and alcohol de- Strengths and limitations
pendence was less likely to be attributed to both brain disease and
negative life events as causes. In another review, Schomerus et al. This study has various strengths including a relatively large sample
(2010) found that the public viewed alcohol-dependent patients as size and the use of standardized questionnaires to assess for responses
having more responsibility for their condition and a reflection of across multiple disorders, thus aiding to expand the dearth of research
“weakness of character” in contrast to those who are suffering from which have analysed differences in nursing students' perception across
schizophrenia and depression. Additionally, those presented with the various mental disorders. However, the present study has a few lim-
‘depression’ vignette were more likely to perceive the person as ‘weak itations. The study is limited to analyses done based on the two scales in
not sick’ as compared to those presented with ‘schizophrenia’, as they the study – DSS and SDS. There may be other aspects of stigma that
may have associated depression with psychosocial causes instead of persist amongst nursing students such as behavioural discrimination
biological causes, thereby assuming that one could be resilient against that was not measured in this study. Lastly, a vignette-based approach
it. By extension, some people believe depression to be associated with a may not reflect respondents' actual behaviour in real life. Future re-
fluctuation of mood that is within the individual's control as opposed to search should look into conducting qualitative studies that examine
it being a disorder (Schomerus, Matschinger, and Angermeyer, 2006), students' experience during clinical placements to explore their influ-
seeing them as weak and responsible for their own condition (Aromaa, ence on attitudes towards mental disorders and gain a more insightful
Tolvanen, Tuulari, and Wahlbeck, 2010). understanding of their experiences.
Participants who were presented with the ‘depression’ or ‘OCD’
vignette reported significantly lower scores on the ‘dangerous/un- Conclusion
predictable’ dimension as compared to those presented with schizo-
phrenia. It was also found that those presented with the ‘depression’, While there is relatively low endorsement of stigmatizing attitudes
OCD’ or ‘dementia’ vignette reported significantly lower scores on the amongst nursing students in Singapore towards people with mental
‘social distance’ dimension as compared to those presented with the disorders, efforts are still needed to address existing stigma towards
‘schizophrenia’ vignette. Previously, Schomerus et al. (2010) found that certain types of mental disorders. Further exploration into the corre-
participants perceived persons with schizophrenia to be more dan- lation between nursing education and clinical placements are crucial to
gerous and desired greater social distance from them as compared to form a better understanding of how these platforms influence the level
those with depression or anxiety disorders. Angermeyer and Dietrich of stigma amongst students. Perhaps the psychiatric nursing education
(2006) found that labels elicited the belief that those who are affected could deal with stigma in a more effective way by addressing mis-
with schizophrenia are dangerous and unpredictable, and in turn trig- conceptions of individual mental disorders during teaching and clinical
gers negative emotional reactions such as fear and aggression. This placements as well. Essentially, enriching students' clinical placements
consequently results in increasing desire for social distance. Notably, experience would be vital in helping to ameliorate stigmatizing atti-
the vignette that participants were presented with did not confirm the tudes amongst nursing students.
type of diagnosis, only examples of its symptomology. Thus, partici-
pants who endorsed stigmatizing attitudes may have done so on the Conflict of interest
basis of perceiving the symptoms and behaviours of those with schi-
zophrenia as out of the ordinary, alarming or bizarre. None.
Male participants were significantly associated with lower social
distance scores as compared to female participants, suggesting that they Acknowledgment
are more likely to be willing to make social contact with persons with
mental disorders than the latter participants. Results were not con- The authors would like to thank the schools for allowing us to
sistent with the few prior studies that explored associations between conduct the study amongst their students. We also want to thank the
gender and stigmatizing attitudes. Some found women to be less stig- participants for their time and efforts in the study. This research was
matizing than men (Angermeyer, Matschinger, and Holzinger, 1998; supported by the Singapore Ministry of Health's National Medical
Farina, 1981), while other studies found no significant gender differ- Research Council under the Centre Grant Programme (Grant No.:
ence (Chou and Mak, 1998). Even though this study showed that male NMRC/CG/004/2013).
participants were less likely to desire social distance from people with
mental disorders, the underrepresentation of male participants in this Appendix A. Supplementary data
population is a concern as it makes it difficult to draw conclusions on
gender based differences. Supplementary data to this article can be found online at https://

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doi.org/10.1016/j.apnu.2018.06.003. Psychiatry, 8(1), http://dx.doi.org/10.1186/1471-244x-8-25.

Griffiths, K. M., Christensen, H., Jorm, A. F., Evans, K., & Groves, C. (2004). Effect of web-
based depression literacy and cognitive-behavioural therapy interventions on stig-
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