Impact of the “Like Minds,Like Mine” anti-stigma and discrimination campaign in New Zealand on anticipated and experienced discrimination

Abstract

Objective:

The “Like Minds, Like Mine” anti-stigma and discrimination programme has been running in New Zealand since 1997. We aimed to investigate the nature and degree of anticipated and experienced discrimination reported by people with mental illness, and their views on whether the campaign was contributing to reductions in stigma and discrimination.

Methods:

Questionnaires were sent to randomly selected people who were representative of those who had recently used mental health services in New Zealand. The measure used was the modified Discrimination and Stigma Scale (DISC-12), adding questions on the effect of “Like Minds, Like Mine”, and also assessing overall changes in discrimination in the previous 5 years.

Results:

A total of 1135 participants completed the questionnaire. This included 225 Ma–ori, 196 Pacific, and 152 Asian persons. Over half of all participants reported improvement in discrimination over the previous 5 years, and 48% thought that the “Like Minds Like Mine” programme had assisted in reducing discrimination “moderately” or “a lot”. Nevertheless, a clear majority (89%) reported experiencing at least “a little” unfair treatment in the previous 12 months due to their mental health problems. The primary source of both positive and negative discrimination was the family. Many (57%) participants had concealed or hidden their mental health problems from others, and 33% had stopped themselves from applying for work because they anticipated discrimination.

Conclusions:

Family, friendship, and social life were the most common areas of discrimination reported by the participants; however, many believed the overall level of discrimination had reduced over the previous 5 years. Overall, these results characterize the nature of stigma and discrimination anticipated and experienced by people with mental health problems and indicate modest but clear and positive recent progress in their reduction.

Keywords

Anti-stigma discrimination “Like Minds,Like Mine”New Zealand stigma

Introduction

Reducing stigma involves addressing problems of knowledge (ignorance or misinformation), problems of attitudes (prejudice), and problems of behaviour (discrimination) (Hinshaw, 2007; Link and Phelan, 2001; Scambler, 1998; Thornicroft et al., 2007). The impacts of stigma include reduced opportunities for full citizenship or to access employment, health care, or social participation (Griffiths et al., 2011; Gulliver et al., 2010).

Studies of discrimination within the field of stigma research have become more common in recent years. These have been conducted across many countries and continents to assess aspects of stigma, for example in Africa (Alem et al., 1999), Asia (Thara et al., 2003), Latin America and the Caribbean (de Toledo Piza and Blay, 2004), south-west Asia (Al-Krenawi et al., 2004), and Europe (Sartorius and Schulze, 2005). There is now also a growing literature assessing the effectiveness of interventions to reduce various aspects of stigma and discrimination (Ando et al., 2011; Clement et al., 2013; Corrigan et al., 2012; Holzinger et al., 2008; Mansouri et al., 2009; Mittal et al., 2012; Schachter et al., 2008; Yamaguchi et al., 2013), and knowledge is substantially expanding on population-level interventions to improve mental health-related literacy (Angermeyer et al., 2009; Jorm, 2011).

Regarding the assessment of discrimination, cross-sectional studies of schizophrenia (Thornicroft et al., 2009) and major depressive disorder (Lasalvia et al., 2013) have recently shown how common both anticipated and experienced discrimination are in many countries worldwide. Within England, the Viewpoint survey is one element in the evaluation of the national anti-stigma programme called “Time to Change”, in which over 1000 service users complete telephone interviews each year to assess changes in anticipated and reported experienced discrimination (Corker et al., 2013; Henderson and Thornicroft, 2009, 2012; Rose, 2001). The results of the first phase of the Time to Change anti-stigma in England programme show a fairly consistent pattern of small and positive changes over the period of the campaign in relation to: public knowledge, attitudes, and behaviour (Evans-Lacko et al., 2013a); newspaper coverage (Thornicroft et al., 2013); employers’ views (Henderson et al., 2013); the impact of social marketing (Evans-Lacko et al., 2013c); and overall cost-effectiveness of the programme (Evans-Lacko et al., 2013b), although no clear impact was shown for local initiatives to reduce stigma among medical students (Friedrich et al., 2013).

Discrimination can also lead people who are stigmatized to anticipate that they will experience discrimination in whatever they undertake, such as looking for a job, where this can itself be profoundly discouraging and disabling. An example of one of the consequences of anticipated discrimination is reduced help seeking and healthcare utilization for both physical and mental health treatments (Jones et al., 2008). Anticipated discrimination can also lead to the avoidance of important activities, for example, applying for work or initiating close personal relationships (Rusch et al., 2005; Thornicroft, 2007; Wahlbeck et al., 2011).

The “Like Minds, Like Mine” programme to reduce stigma and discrimination associated with mental illness began in New Zealand in 1997, which placed New Zealand at the forefront of countries introducing such programme. It includes a mass media campaign, community workers, and policy initiatives, for example including national and international celebrities such as the rugby player John Kirwan, alongside “ordinary” individuals in a series of social marketing elements to the campaign as a whole. There is a strong focus on involvement and leadership by people with experience of mental illness, particularly for the community-level initiatives. Further information on the programme is available at www.likeminds.org.nz or publications (Phoenix Research, 2010; Wyllie et al., 2005).

The “Like Minds, Like Mine” programme impacts have been monitored via regular tracking surveys with random samples of 1000 members of the 15–44-year-old target audience (Phoenix Consulting, 2005; Phoenix Research, 2010). These have shown improvements in public attitudes and behaviours (Wyllie et al., 2013). One previous survey sought to identify the impacts of the programme for mental health service users (Akroyd and Wyllie, 2003); however, the sample for that survey was not randomly selected. Another nonrandom survey of service user experiences of discrimination was undertaken by the Mental Health Foundation in 2003 (Peterson et al., 2004), but this did not attempt to evaluate the impact of the “Like Minds, Like Mine” programme.

In this context, the overall aim of this study was to investigate the experiences of a representative sample of New Zealand users of mental health services in 2010 in order to assess their reports of discrimination. More specifically, the study aims were to measure service user reports of anticipated and experienced in order to:

establish a baseline to allow for tracking changes over time in service user reported experienced and anticipated discrimination which can be used in the future as a baseline for longitudinal studies

identify perceived levels of discrimination and their changes during 2005–2010

assess experiences of being treated more positively because of mental health problems

identify the perceived impact of the “Like Minds Like Mine” programme.

Methods

Study sites

Data collection for the main survey took place between 20 September 2010 and 19 January 2011 in 10 of the 21 District Health Boards (DHBs) across the whole of New Zealand, using the Ministry of Health Programme for the Integration of Mental Health Data (PRIMHD) database. For budgetary reasons, and also not to impose excessive administrative burdens on DHBs, it was necessary to limit the number of DHBs in the study to 10. The DHBs were selected to provide a fair and representative spread in terms of: ethnic composition, geographic location, urban/rural, and level of deprivation so that the study results would be reasonably generalisable to the whole country. The DHBs included were: Auckland, Canterbury, Counties Manukau, Northland, Taranaki, Mid Central, Capital and Coast, Waikato, Otago, and Southland (the last two have since been merged into one DHB). The selection process entailed the Ministry dividing the current service user database for the 10 selected DHBs into 16 cells (four ethnicity groups by two gender groups by two age groups). The Ministry then randomly selected the required number from each cell, as specified by Phoenix Research (based on ethnicity of the New Zealand DHB service user population, allowing for males having lower response rates). The sample was selected from all users of DHB mental health services for the 12 month period ending 30 June 2010 with the following exceptions: (i) those who had died before the start of the study; (ii) those in psychogeriatric wards; and (iii) those with intellectual disability.

Study sample

The Ministry of Health agreed to undertake the random selection of the sample for the specified DHBs. We obtained ethical approval from the Ministry of Health Multi-Region Ethics Committee for the researchers (Phoenix Research) to send the consent form to potential participants who were then invited to return these to Phoenix Research, who sent out the study measures to consenting participants on behalf of the Ministry of Health. This approach did mean that the identity of the survey participants became known to Phoenix Research, but none of the participants’ mental health data was available to them. Phoenix Research ensured this information remained fully confidential.

The sample was selected from users of DHB mental health services for the 12-month period ending 30 June 2010. Māori, Pacific Island, and Asian people were oversampled to provide sufficient sized numbers for each group. Prior to analysis, the data were weighted so that the participants were representative of all users of DHB mental health services in terms of ethnicity, gender, and young people. Prior to analysis of the data, the achieved sample was weighted to provide total sample figures where the gender, age (16–24 and 25 years and over) and ethnic composition (Māori, Pacific, Asian, Other) matched the proportions for all DHBs supplying data to PRIMHD.

Young people (16–24 year olds) were oversampled, having a disproportionately high number of questionnaires sent out, because they often have a low response rate. To enhance response rates from Pacific and Asian participants, they were sent a questionnaire and associated material (covering letter, information sheet) translated into their Pacific language, as well as the English version. The Pacific and Asian groups were oversampled to provide sufficient sized numbers for each group. This was then adjusted for by weighting prior to analysis, to reflect the ethnic composition of all service users in the 12-month period that the sample was drawn from.

Measures

The main scale used for this study was a self-completed version of the Discrimination and Stigma Scale (DISC-12) (Brohan et al., 2013). The DISC-12 is a structured measure used to record reports of a person with experience of mental illness on their experience of discrimination across specified life domains. Translation and cross-cultural adaptation of DISC-12 have been completed in many languages worldwide. The validity and reliability of this measure when administered face to face has been established (Brohan et al., 2013).

The DISC-12 contains questions on aspects of everyday life, including work, marriage, parenting, housing, leisure, and religious activities. The instrument also considers how far participants limit their involvement in areas of social participation due to the anticipation of discrimination. DISC-12 ratings are given on a 4-point Likert scale ranging from “not at all” to “a lot”. The discrimination questions all ask about being “treated unfairly” (e.g. “Have you been treated unfairly in making or keeping friends?”) and anticipated discrimination (e.g. “Have you stopped yourself from applying for work?” or “Have you concealed or hidden your mental health problem from others?”).

When assessing change over time, the first question asked, “Thinking about all possible ways of being treated unfairly because of your mental illness, compared with 5 years ago, has this got: a lot better, a little better, no change, a little worse, a lot worse?” Participants were asked, for the ratings of progress to reduce discrimination, to give their views of overall progress at the national level over the previous 5 years. The second question asked just about changes in any unfair treatment by mental health staff. These questions were only asked of participants who had their first contact (n=531).

There were five items where participants rated whether they had been treated more positively in the previous 12 months because of their mental health problems. There were also two questions about overcoming stigma and discrimination: using their personal skills or abilities in coping with stigma and discrimination; and making friends with people who don’t use mental health services.

Socio-demographic and clinical information were also recorded (age, gender, ethnicity, years since first contact with mental health services, work status, education, current mental health care, other types of mental health care received in previous 5 years, whether under the Mental Health Act in the previous 12 months).

This was the first time the DISC-12 was used as a self-completion version, as all previous studies having entailed face-to-face (Lasalvia et al., 2013) or phone interviews (Corker et al., 2013). In adapting the interview version of the DISC-12 to the self-completion version used in this study, a few minor aspects of wording were modified to make it more appropriate for New Zealanders. In addition, a small number of extra items were added to the overall assessment which were relevant to the New Zealand context: for example, how much service users felt discrimination had improved or deteriorated in the previous 5 years. The use of the DISC-12 in the self-administered version did not generate any lack of clarity or understanding of the items or process for completion as reported by participants, and no formal process to measure the psychometric properties of the self-administered scale was performed.

Two scores were generated. The first was the “experienced discrimination scale”, which was a count of the total instances of endorsement of a negative experienced discrimination for the first 26 items, using the methods of the previous DISC-12 studies (Lasalvia et al., 2013). The second score was generated from the four “anticipated discrimination” items which assess how far the individual has stopped himself or herself from applying for work, applying for education/training courses, or having a close relationship or has concealed or hidden their mental health problem from others. We also rated any relevant positive experienced from the perspective of service users by including the question: “We would like to ask you about times in the last 12 months when you have been treated more positively because of your mental health problems”.

Peer-review of the study method

The methodology and adapted measure were peer-reviewed by an international researcher and by a national service user research expert. In addition the following groups were consulted on the study methodology: Ministry of Health; Service User Advisory Group, convened by Phoenix Research, which included Māori and Pacific Islander representatives, Like Minds Maori Caucus, Like Minds Pacific Provider Fono, and DHB mental health managers and clinical directors. The proposed research methods were also presented and discussed at two of the annual “Like Minds Like Mine” provider seminars.

Data analysis

Chi-squared tests were used for comparisons of counts, and t-tests were used for comparisons of continuous variables (averages). All tests were two tailed. The Chi-squared tests were all corrected for continuity using Yates formula. Subgroup analyses were compared with the total sample and are reported for people who had been detained under the Mental Health Act, those using drug or alcohol services, for Māori people, and by gender.

Results

Response rate and socio-demographic data

A total of 1135 participants completed the questionnaire. This included 225 Māori, 196 Pacific, and 152 Asian persons. The sample included 190 young persons (those aged 16–24 years), which was 17% of the whole sample, and so this was weighted up to 20% to reflect their correct proportion among service users as a whole. The alcohol and other drug subsample generated 39 participants. Regarding respondents from minority ethnic groups, only a small number of translated questionnaires were returned: eight Samoan, five Niuean, five Tongan, four Cook Island Māori, and 20 Chinese. There was therefore a low response rate for people in these ethnic groups and they were still underrepresented in the completed questionnaires.

In this study, the overall response rate was 18%, and this was somewhat higher among service users who had more than 10 contacts with DHB mental health services in the previous 12 months (21%). Table 1 shows the numbers responding for different subgroups and their unweighted and weighted percentage of the total sample.

Table 1.

Socio-demographic and clinical characteristics of the participants.

	Total sample	Total sample (unweighted)	Total sample (weighted)
	n	%	%
Ethnicity
Māori	225	20	20
Pacific	196	17	8
Asian	152	13	4
Other	728	64	80
Not answered	6	1	0
Age (years)
16–24	190	17	20
25–44	474	42	38
45–64	412	36	37
65 or over	58	5	5
Not answered	1	0	0
Gender
Female	643	57	47
Male	490	43	53
Not answered	2	0	0
Highest level of education
University degree/diploma	241	21	19
Other tertiary qualification	203	18	18
Tertiary study
Not completed	169	15	15
High school/other school	436	38	42
Not answered	85	7	6
In paid work
Full-time (30+ hours a week)	158	14	14
Part-time	205	18	17
Not in paid work	723	64	65
Not answered	49	4	4
Under Mental Health Act in the last 12 months
Yes	367	32	31
No	727	64	66
Not answered	40	4	3
Bed nights in the last 12 months
1–2	259	23	24
3–10	314	28	28
11–25	248	22	21
26 or more	279	25	23
Not specified	35	3	3
Time since first contact with mental health services (years)
0–4	517	46	45
5–9	173	15	15
10–19	179	16	16
20 or more	152	13	15
More than 5 years but not stated	27	2	2
Don’t know	40	4	3
Current main type of mental health care
In-patient/hospital services	43	4	4
Community mental health services	636	56	57
Other	207	18	19
None	264	23	23
Not answered	26	2	2
Total types of mental health care in the last 5 years
In-patient/hospital services	364	32	33
Community mental health services	872	77	78
Other	305	27	28
None	89	8	8
Not answered	17	1	1
Users of alcohol or drug services	29	3	3

Discrimination

Most people (89%) reported experiencing negative discrimination in at least one domain in the previous year, with an average of 7.4 of the 26 relevant questions being answered with a “a little, “moderately, or “a lot”. Figures 1 and 2 show the levels reporting each form of discrimination. There are two totals provided to the columns to the right of each item. The first is the total for “a little, moderately, or a lot” (i.e. any discrimination reported) and the second is the total for “moderately, or a lot” (i.e. only the more severe discrimination is included). In terms of the latter, the most commonly experienced forms of discrimination were: by family members (30%) in making or keeping friends (28%), being avoided (shunned) by people who know you have a mental health problem (26%), in dating or intimate relationships (24%), in finding a job (22%), or in marriage or divorce (21%).

Figure 1.

Experienced discrimination in personal life.

Figure 2.

Experienced discrimination from wider society.

Discrimination by mental health staff

Overall, discrimination by mental healthcare staff was the twelfth most commonly mentioned domain and was reported by 16% of all participants for “moderately or a lot”. Those having the most contact with mental health services (more than 25 contacts in the previous year) reported a higher occurrence of being treated unfairly by mental healthcare staff (26%). Among this group of high users, this was the fifth most mentioned source of discrimination, after making/keeping friends (36%), family (33%), avoided by people who know you have mental health problems (27%), and dating and intimate relationships (26%).

Subgroup comparisons

Regarding the differences between key subgroups and the whole sample, the most striking were as follows (all of which were significant at the p<0.05 level; figures refer to the subsample and the whole sample, respectively). People who had been under the Mental Health Act in the previous 12 months on average reported discrimination more often in relation to finding a job (28 vs. 20%) and contact with the police (23 vs. 13%). Users of alcohol or drug services more often reported discrimination in relation to dating or intimate relationships (45 vs. 23%), finding a job (38 vs. 22%), contact with the police (30 vs. 16%), and getting hospital/physical help (31 vs. 14%). Māori people more often reported discrimination than the whole sample in relation to personal safety and security (26 vs. 19%), and contact with the police (23 vs. 16%). Men more often reported discrimination than women for finding a job (26 vs. 18%), and keeping a job (22 vs. 15%).

Anticipated discrimination

Most participants (84%) reported that they had anticipated discrimination by others. As Figure 3 shows, the majority (57%) had concealed or hidden their mental health problems from others, while 37% had stopped themselves from trying to initiate a close relationship, 33% had not applied for work, and 24% had not applied for educational or training courses.

Figure 3.

Anticipated discrimination.

Overcoming stigma and discrimination

More positively, 42% reported being able to use their personal skills or coping abilities in relation to stigma and discrimination. A similar proportion (43%) had made friends with people who did not use mental health services.

Positive treatment

On five items, service users rated whether they had been treated more positively in the last 12 months because of their mental health problems. Four out of five service users (79%) reported at least “a little” on at least one of the five items and 58% either “moderate” or “a lot”. There were 40% who felt they had been treated more positively (either “moderately” or “a lot”) by their family because of their mental health problems. This compared with 30% who reported being treated unfairly by their family, as noted previously. There were 9% who reported being treated both more positively and also unfairly by their family.

More than one in five (22%) reported being treated more positively by Work and Income New Zealand, which is a government department supplying financial assistance and employment services throughout New Zealand. This compared with 20% who reported unfair treatment. A similar proportion (21%) reported being treated more positively in their housing/accommodation, which compared with 16% who reported being treated unfairly. Fifteen per cent reported they had been treated more positively in their religious activities, which compared with 7% who reported unfair treatment. The least mentioned example of being treated positively was for paid employment (including obtaining jobs and suitable working conditions), which was mentioned by 12%.

Recent changes in discrimination levels

Overall, just over a half (54%) reported that there had been some improvement in stigma and discrimination in New Zealand over the previous 5 years. This question was asked of the 531 participants who had used mental health services for at least 5 years. Conversely, there were 16% who reported that this had become worse over this period and there were 19% who thought there had been no change. When considering unfair treatment by mental health staff, there were 42% who thought that this had improved over the previous 5 years, compared with 11% who reported that it had become worse.

Perceived impact of “Like Minds, Like Mine”

As demonstrated by Figure 4, almost half (48%) the participants thought the “Like Minds Like Mine” programme, including its TV advertising, had assisted in reducing discrimination against people with mental illness “a lot” or “moderately”, while a further 22% felt it had assisted “a little”. Only 8% expressed the view that it had not assisted.

Figure 4.

Perceived impact of “Like Minds Like Mine”.

Discussion

This survey has provided baseline levels of service user reported discrimination, against which to assess the future performance of the “Like Minds Like Mine “ programme (Vaughn, 2004). Indeed most participants did report that the campaign, at least over the last 5 years, has made a positive contribution towards reducing mental health-related stigma and discrimination in New Zealand. The most common source of both discrimination and positive treatment was reported as the family, emphasizing the frequently dual and conflicting contributions in relation to discrimination and stigma. These findings are likely to relate to family being the people who many service users will have the most contact with and therefore providing more opportunity to be treated unfairly. However, these findings are important not least because family members are often the people with whom study participants have the closest relationships and who are often in the best position to refer the affected individuals for assessment and treatment: for example, following training in mental health first aid (Jorm et al., 2005). Further qualitative research prior to the current campaign found that families need as much support as service users (Phoenix Research, 2010), and indeed family members may also themselves experience “stigma by association” (Peterson et al., 2004). In the current research, the difficulty of establishing other friendships/relationships was illustrated by relatively frequent ratings by participants who stopped themselves from initiating close personal or intimate relations because of fear and anticipation of failure, exacerbating social isolation (i.e. by various manifestations of social distance; Pescosolido et al., 2010; Reavley and Jorm, 2011).

Implications of findings for mental health staff

It is noteworthy that over 40% of participants reported discrimination by mental health staff had improved in the previous 5 years. This may be attributable in part to the “Like Minds Like Mine” programme, including the changing climate of opinion due to the mass media campaign, plus some mental health staff have attended “Like Minds, Like Mine” workshops. There has also been a strong emphasis by the Mental Health Commission on promoting the concept of recovery. The Ministry of Health has also developed “Let’s Get Real”, which sets out values and attitudes, and a set of seven “Real Skills”, for people working in mental health and addiction. While the majority of users of mental health services are not reporting being treated unfairly, there is still clearly room for improvement. Given mental health services are where people go for treatment of their mental illness, it is very important that service users do feel that they are treated fairly. In this respect, these results mirror many of the findings of the “beyondblue” campaign in Australia to reduce stigma related to depression (Christensen et al., 2004; Griffiths et al., 2004; Hickie, 2004; Jorm et al., 2006).

On being treated more positively

The primary focus in the survey was on discrimination; however, it is also important to acknowledge the efforts that are being made to provide appropriate support to service users. The fact that the many respondents said that they are now being treated more positively is encouraging testimony to national secular trends.

Results compared to previous studies of discrimination

Our results are very similar to those of an international study of people with schizophrenia, which was a cross-sectional study of 27 countries using a face-to-face form of the DISC-12 scale. In both studies, the two highest areas of negative discrimination were family and friends (Thornicroft et al., 2009). A difference between the papers is that the earlier study did not ask about longer-term trends in experienced discrimination. A recent similar study, which reported the use of DISC-12 in 35 countries worldwide for participants with depression, also reported that the family was the most frequent domain for negative experienced discrimination towards participants (40% for “a little”, “moderately”, or “a lot”). Notably, that depression study reported a 37% level of anticipated discrimination relating to preventing oneself from entering a close personal relationship, somewhat less than the 52% found in our study. Taking a broader perspective, it is instructive to consider these findings in relation to studies in sites where no anti-stigma programmes were taking place. The literature here does not offer a positive picture: studies giving population-level attitudes towards people with mental illness over the last 10–20 years in Germany (Angermeyer et al., 2013) and the USA (Pescosolido et al., 2010) have shown attitudes towards people with depression and alcohol misuse remaining largely unchanged, while attitudes towards people with schizophrenia deteriorated. Similarly a comparison between such public attitudes in England and Scotland showed an overall worsening of social distance (before the start of the Time to Change campaign) compared with some aspects of improvement in Scotland during the See Me campaign there (Mehta et al., 2009).

Another relevant comparison is between this study and that published by Corker et al. (2013) which used a similar methodology in investigating the impact of the “Time to Change” programme in England, comparing results from a DISC-12 questionnaire annually between 2008 and 2011 (Henderson and Thornicroft, 2013). A very similar proportion (91%) reported experiencing discrimination, compared to 89% in our study. Another aspect in common was the identification of family and friends as the main source of discrimination. In the Corker paper, 72% of participants felt the need to hide their condition to some extent, notably similar to 74% in this study in New Zealand.

Limitations of study

In this study, three key demographic groups – Asians, young people (16–24 years old), and those in the alcohol or drugs category – were underrepresented. Despite young people and Asians being oversampled during the send-out of out questionnaires, all three groups had to be adjusted in weighting of the data prior to analysis. Being able to obtain more accurate information directly about these three groups would have been very useful for identifying their individual needs and experiences in regard to discrimination. Further, the method of asking participants to make an overall judgment of how discrimination has changed over a defined prior period runs the risk of retrospective bias, although at the same time we do attach importance to the statements by a relatively large sample size of service users to their views on this matter.

Implications of the study

As with other similar studies, the attitude of the family and friends has been identified as the most important domain in which discrimination is identified by participants. This has been the focus of the current phase of the “Like Minds, Like Mine” campaign, and further work should be carried out to educate people close to those with mental health issues. While the positive impact of “Like Minds, Like Mine” is being felt by service users, it remains true that the high incidence of anticipated discrimination in New Zealand suggests that this should be a focus of further attention through a specific and sustained focus upon the personal as well as upon the public manifestations of stigma and discrimination.

Footnotes

Acknowledgements

We wish to express our sincere gratitude to all those who gave their time to complete this survey.

Funding

This research was funded by the Ministry of Health in New Zealand. Graham Thornicroft is funded in relation to a National Institute for Health Research (NIHR) Applied Programme grant awarded to the South London and Maudsley NHS Foundation Trust and in relation to the NIHR Specialist Mental Health Biomedical Research Centre at the Institute of Psychiatry, King’s College London and the South London and Maudsley NHS Foundation Trust.

Declaration of interest

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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