Post on 13-May-2023
ORIGINAL PAPER
Public knowledge, beliefs and attitudes towards patientswith schizophrenia: Buenos Aires
Eduardo Adrian Leiderman • Gustavo Vazquez • Candela Berizzo •
Ana Bonifacio • Noelia Bruscoli • Juan I. Capria • Betina Ehrenhaus •
Manuel Guerrero • Maria Guerrero • Maria Lolich • Roumen Milev
Received: 16 December 2008 / Accepted: 3 February 2010
� Springer-Verlag 2010
Abstract
Objective The purpose of our study was to assess the
knowledge, social distance and perception of social dis-
crimination towards persons with schizophrenia in the
general adult population of Buenos Aires, Argentina.
Methods One thousand two-hundred fifty-four persons
were surveyed at different neighborhoods of the city of
Buenos Aires. Their knowledge about schizophrenia, per-
sonal social distance and perception of social discrimina-
tion were assessed with several questions. Afterwards, a
scale for each one of these measures was built.
Results Almost half of the general population believed
that patients with schizophrenia suffer from split person-
ality and that most of them are dangerous and violent.
Knowledge about schizophrenia in the general population
was moderate and it was associated with age and educa-
tion. Almost 80% of the population had less than one-third
of the maximum possible social distance score, but their
perception of social discrimination was high. Social dis-
tance was greater in the elderly. Knowledge was correlated
weakly with social distance. Respondents directly related
with patients suffering from schizophrenia were more
knowledgeable about the illness, but had the same social
distance and perception of social discrimination than the
rest of the general population.
Conclusions The persons surveyed felt their own atti-
tudes are more favorable to people with schizophrenia than
‘most other people’s’ attitudes. The elderly should be
specifically addressed in specially designed anti-stigma
campaigns.
Keywords Schizophrenia � Discrimination � Stigma �Social distance � Mental health literacy
Introduction
Schizophrenia is a severe and persistent mental disorder,
affecting approximately 0.5–1% of the population [4]. It is
often chronic and it can bring significant functional
impairment for the individual and create a burden for
society [12, 42]. Nevertheless, numerous factors are asso-
ciated with outcome, and different interventions may allow
the vast majority of patients to live in the community and
increase their likelihood of sustained recovery. Studies
have found that between 5 and 22% of the patients recover
from a first episode without subsequent recurrence of
symptoms [29, 54], and that almost 40% of people with
schizophrenia can enjoy a sustained and functional recov-
ery after one or more psychotic episodes [25].
Schizophrenia has always provoked public interest since
some of its symptoms, such as delusions and hallucina-
tions, are difficult to comprehend. Patients with schizo-
phrenia rarely commit serious crimes, but when they do,
they might be so bizarre and unpredictable, that the media
give them a significant attention [40, 53].
Stigma refers to the negative attitudes and beliefs held
towards patients with schizophrenia [49]. Knowledge about
schizophrenia, or lack thereof, can shape the attitudes and
behavior of the public. Discrimination occurs when the
rights and freedoms of a person with schizophrenia are
denied because of their illness. The experience of stigma
and discrimination because of schizophrenia may be
E. A. Leiderman (&) � G. Vazquez � C. Berizzo �A. Bonifacio � N. Bruscoli � J. I. Capria � B. Ehrenhaus �M. Guerrero � M. Guerrero � M. Lolich � R. Milev
Universidad de Palermo, Buenos Aires, Argentina
e-mail: edule@psi.uba.ar
123
Soc Psychiat Epidemiol
DOI 10.1007/s00127-010-0196-0
devastating for the individual and can be detrimental to
recovery [9, 33, 34]. Negative consequences, such as
reduced employment [39], lower self esteem [37] and
depression [36] have been reported with stigmatization,
and people who perceive discrimination are more disabled
and more symptomatic [22].
There have been numerous attempts to measure the
knowledge of the general population about mental illness
in general and schizophrenia in particular. Attitudes
towards people with schizophrenia have been usually
assessed by rating social distance. Most studies utilized a
modified version of a scale designed to measure attitudes
towards cultural minorities [10, 28].
The respondent’s sociodemographic characteristics,
such as age, social class and level of education have reg-
ularly been found to influence attitudes towards people
with mental illness on studies carried out in developed
countries [5, 55].
There is a scarcity of information about perception of
mental disorders and stigmatization of people with
schizophrenia in Latin America [52] and specifically in
Argentina. Up to date, only small studies about attitudes
towards mental illness in Argentina have been published.
These studies revealed that the surveyed have a propitious
attitude toward the people with mental illness (measured by
the Scale of Attitudes toward mental illness of Stefani) [45,
46]. The attitude was more favorable in individuals with
higher socioeconomical and education level and lower
degree of authoritarianism [45, 46]. However, large-scale
studies about attitudes towards mental illness have not been
done in this country.
In this study, we attempt to evaluate the knowledge,
social distance and perception of social discrimination in
the general adult population of Buenos Aires, Argentina
and compare them with other international studies. We also
try to determine whether demographic characteristics of the
respondents and their familiarity with people with schizo-
phrenia correlate with each one of the studied variables.
Methods
Sampling
We carried out a survey among inhabitants of Buenos
Aires, Argentina, aged 18 years and older, between May
and September of 2007. A non-probability sample of 1,254
respondents was selected using convenience sampling. The
survey was conducted by eight psychology students of the
University of Palermo at Buenos Aires. Raters received
several training sessions at the university to ensure inter-
rater objectivity. People were surveyed on the streets, in
parks, public transportation stations and commercial
centers of almost all neighborhoods of Buenos Aires City.
Raters were instructed to approach every person at a first
passed—first surveyed basis. Consent was considered to be
given with the agreement of the individual to complete the
interview. The calculated response rate for the survey was
67.5%.
Questionnaire
The survey consisted of an interviewer-assisted ques-
tionnaire of 33 items. The interviewer read the questions
carefully and probed all items. The survey was divided
into five sections. In the first section, demographic data
of the surveyed were collected (gender, age, education,
socioeconomical level). In the second section, we asked
about their existing relationship with persons with mental
illness and more specifically with persons suffering from
schizophrenia, along with a measure of personal experi-
ence with psychiatric or psychological treatment or work
in the mental health field. In the third section we asked
10 questions to assess the respondent knowledge about
schizophrenia. This questionnaire was partly derived from
the questions used in previous studies [23, 48]. In the
fourth section, the respondents’ social distance towards
people with schizophrenia was measured with the modi-
fied six-item version of the Bogardus social distance scale
for rating stigmatising attitudes toward cultural minorities
[10], which was used in previous studies [2, 23, 48]. The
following issues were investigated: marrying somebody
with schizophrenia, having a friend with schizophrenia,
being upset about working with someone with schizo-
phrenia, being disturbed by having a neighbor with
schizophrenia, being afraid of talking to someone with
schizophrenia, and being ashamed of having a family
member with schizophrenia. The answers were changed
into a Yes/No format to ‘‘force’’ the respondents into
making a choice. Finally, in the fifth section, the per-
ception of social stigmatization was assessed by 6 items
of the Link’s Discrimination—Devaluation scale [35].
The items are statements about the perceived social
stigmatization towards people with schizophrenia and
other mental illnesses. We added as in a previous study
[23] a gender-specific statement about the attitudes of
women to complement the item about men’s attitudes.
Again, the respondents were asked to answer in a Yes/No
format.
The translation-back-translation methodology was used
to create a semantic and cultural adaptation to our country
of the questionnaire of these two last sections, following
different guidelines [15, 44]. The first author of this study
(E.L.) originated a Spanish version of the questionnaire
which was translated into English by a professional offi-
cial public translator that was blind to the original
Soc Psychiat Epidemiol
123
questionnaire [13]. The English version was then revised
by the senior author (R.M.) of this article and back-
translated by the second author (G.H.V.). After appro-
priate corrections for nuance, the final version was used
for our study.
Statistical analysis
To analyse results by age, we divided the sample into three
groups: group 1: respondents from 18 to 30 years old,
group 2: respondents from 31 to 64 years old and group 3:
respondents 65 years of age or older.
Each answer for knowledge, social distance and per-
ception of social stigmatization was converted into a score.
The knowledge score reveals the number of correct
answers (0–10). This knowledge scale has an internal
consistency of 0.69 (Cronbach’s a). The social distance
score varies from 0 to 6, with 0 being the nearest social
distance achievable and 6 the most distant one. This scale
has an internal consistency of 0.70 (Cronbach0s a). The
perception of social stigmatization score varies from 0 to 7,
with 0 being the perception of the lower stigmatization by
society, and 7 the perception of the highest. The internal
consistency of this scale was calculated as being 0.77
(Cronbach0s a).
Relative frequencies of the answers are described.
Scores were calculated and compared between groups
using Mann–Whitney and Kruskal–Wallis tests for two or
more independent variables, respectively. Bonferonni’s
corrections were used to adjust for multiple post hoc
comparisons. Spearman correlation coefficients between
scores were used. Multiple linear regression analyses with
knowledge, social distance and perception of social stig-
matization scores as dependent variables and demographic
and familiarity factors as independent variables were per-
formed. Statistical tests were carried out using SPSS ver-
sion 10.0 (SPSS Inc, Chicago, IL, 1999).
Results
Demographics
Demographic data of the surveyed and their experience
with mental illness are presented in Table 1. Age, gender
and education profile of the surveyed were compared with
the Buenos Aires household census (2004–2006) [20, 21]
to assess whether the survey sample was representative of
the general population.
When compared with the census population, younger
and highly educated respondents were over represented;
while those with older age and without complete high
school education were under represented (v2(2) = 248.6,
P \ 0.001 for age, v2(2) = 236.5, P \ 0.001 for educa-
tion). Gender distribution of our sample was not different
than the one of the general population (v2(1) = 0.55,
P = 0.45) (Table 1).
Knowledge about schizophrenia
Detailed answers of the schizophrenia knowledge questions
are described in Table 2. The mean score of correct
answers for all the sample was 4.6 SD 2.4, the median was
5 (skewness = 0.11). Thirty-two percent of the sample had
a score between 0 and 3, 54.3% had a score between 4 and
7 and 13.7% had a score higher than 7.
Demographic variables
There were no significant differences of total knowledge
scores by gender (Table 5).
There was a statistically significant difference of
knowledge by age (Table 5). Mann–Whitney post hoc tests
using Bonferonni’s correction (i.e., 0.05/3 = 0.016)
revealed that older people had more correct answers than
younger ones (age group 1 vs. age group 3: Z = -3.79,
P \ 0.001; age group 2 vs. age group 3: Z = -2.76,
P = 0.006; the knowledge score between age group 1 and
age group 2 was not statistically significant: Z = -2.18,
P = 0.02). There was also a statistically difference of
knowledge by education and by socioeconomic class
(Table 5): post hoc comparisons of education level groups
with Bonferonni’s correction (0.05/6 = 0.008) showed that
people that had complete university or tertiary education
had more knowledge about schizophrenia compared with
the ones that had incomplete elementary school education
(Z = -3.5, P \ 0.001), complete elementary school edu-
cation (Z = -5.39, P \ 0.001) or complete high school
education (Z = -5.9, P \ 0.001).
Post hoc comparisons of socioeconomic class groups with
Bonferonni’s correction (0.05/10 = 0.005) showed that low
socioeconomic level group had significantly less knowledge
than low medium (Z = -3.3, P = 0.001), medium
(Z = -6.1, P \ 0.001) and high-medium level group
(Z = -5.6, P \ 0.001), and that low medium socioeco-
nomic group had less knowledge about schizophrenia com-
pared with the medium level (Z = -7.7, P \ 0.001) and
high-medium level group (Z = -5.3, P \ 0.001).
Familiarity variables
Knowledge scores were compared between the different
familiarity variables.
People who have some kind of relationship with a per-
son with mental illness or with patients with schizophrenia
(e.g. co-workers, neighbors and friends) had more
Soc Psychiat Epidemiol
123
Table 1 Demographics of the sample and comparison with census data
Sample surveyed (N = 1254) General population *
Age (in years)
18 to 30 :
31 to 64:
65 or more:
38.7 SD 14,9 (range: 18–84)
37.3%
56.3%
6.5%
22.7%
56.3%
21.6%
Gender Women
Men
55.3%
44.7%
54.3%
45.7%
Education Incomplete elementary
school
Complete elementary
school
Complete high school
Complete tertiary o
university education
1.3%
12.9%
51%
85.8%
34.8 %
5.1%
29.7%
65.2%
Socio-economical status Low class
Medium-low class
Medium class
Medium-high class
High class
3.5%
20.1%
68.7%
7.3%
0.5%
Relationship with a
person with mental
illness
Yes 33.4%
Relationship with a
person with
schizophrenia
Yes 11.5%
Lives with a person with
mental illness
Yes 9.8%
Lives with a person with
schizophrenia
Yes 2.3%
Has attended or is
attending a psychologist
or psychiatrist
Yes 44.3%
Works in the mental
health field
Yes 5.4%
aData from the annual household survey of the city of Buenos Aires. Educative aspects 2004–2005, demographic aspects 2006; Direccion
General de Estadısticas y Censos (2008)
Soc Psychiat Epidemiol
123
knowledge about schizophrenia than people without that
contact (Table 5).
People living with persons with mental illness or
those with schizophrenia had more knowledge about the
illness than people who do not live with them (Table 5).
Those subjects attending psychological or psychiatric
treatment, or working in the mental health field also had
significantly more knowledge about schizophrenia than
respondents without those characteristics (U Mann–
Whitney Z = -8.09, P \ 0.001 and Z = 5.9, P \ 0.001,
respectively).
Multiple linear regression analysis revealed that
knowledge was poorly predicted by demographic and
familiarity factors (R2 = 0.133, F [8] = 23.7, P \ 0.001)
being socioeconomic class (b coefficient = 0.19, P \0.001), education level (b coefficient = 0.12, P \ 0.001),
age (b coefficient = 0.09, P \ 0.001), relationship with a
person with mental illness (b coefficient = -0.13,
P \ 0.001), relationship with a person with schizophrenia
(b coefficient = -0.07, P \ 0.05) and living with a person
with schizophrenia (b coefficient = -0.06, P \ 0.05)
significant predictor variables.
Social distance
The mean score for the social distance answers was 1.59
SD 1.42, the median was 1 (skewness = 1.21). Relative
frequencies of specific answers are detailed in Table 3.
A percentage of 79.4% of the sample had a score between 0
and 2, 15% had a score between 3 and 4 and 5.6% had a
score [ 4.
Demographic variables
The only statistical difference by sex was in the marriage
item: women were more reluctant to marry a person with
schizophrenia (79.8%) than men (72.9%) (Pearson v2
[1] = 8.3, P = 0.002).
There was a positive correlation between age and social
distance. Older people had a significantly higher social
distance (rs = 0.156, P \ 0.001). Statistical analysis
showed that there were significant differences by age in the
questions related to marriage (‘‘would not marry’’ age
group 1: 69.1%, age group 2 : 80.8%, age group 3: 95.4%;
Pearson v2 [2] = 25.1, P \ 0.001), having a friend with
schizophrenia (age group 1: 76.3%, age group 2: 70.5%
and age group 3 : 64.6%; Pearson v2 [2] = 7.4, P \ 0.001),
and being disturbed about working with a person
with schizophrenia (age group 1: 20.6%, age group 2:
27.3% and age group 3: 35.3%; Pearson v2[2] = 11,3,
P = 0.003).
There was a significant statistical difference of mean
scores for social distance towards persons with schizo-
phrenia by education (Table 5). Mann–Whitney post hoc
test with Bonferonni’s correction (0.05/6 = 0.008)
revealed that the statistical difference was between the
complete elementary school group and the complete high
school group (Z = -2.7, P = 0.006). There was also a
significant difference of social distance score by socio-
economic class (Table 5). Mann–Whitney post hoc
comparisons with Bonferonni’s correction showed that
there was a statistical difference between the low medium
level socioeconomic group and the medium level group
(Z = -3.6, P \ 0.001) and between the medium level
group and the high-medium level group (Z = -3.2,
P = 0.001).
Familiarity variables
People who had an employment related to the mental
health field, lived with a person suffering from schizo-
phrenia or any other mental disorder, or had any kind of
Table 2 Knowledge about schizophrenia (N = 1,254)
People with schizophrenia Yes (%) No (%) Do not know (%)
1 Suffer from split or multiple personalities 44.4 20.7a 34.9
2 Listen to non existent voices 64.7* 9.6 25.7
3 Tend to socially withdraw 50.3* 23.8 35.9
4 Can have lack of will 31.9* 32.9 35.2
5 Are mentally retarded 13.3 63.3a 23.4
6 The majority is dangerous to others or has violent behavior 26.7 46a 27.3
7 Have bizarre or inadequate behavior 69.9* 12.1 18
8 The majority has a cure 22.2 32.8a 45
9 The causes of schizophrenia Genetic 18.1 Environmental 10.4 Both 36.9a 34.6
10 The most adequate treatment Medication 16 Psycho therapy 7.3 Both 51.4a Neither 0.8 24.5
a Answers that were considered correct to build the total knowledge score
Soc Psychiat Epidemiol
123
relationship with them, did not differ with regard to social
distance than the rest of the sample (Table 5).
Multiple linear regression analysis showed that social
distance score was poorly predicted by demographic and
familiarity factors (R2 = 0.02, F [8] = 3.4, P \ 0.001)
being age the only significant predictor variable (b coeffi-
cient = 0.12, P \ 0.001).
Perception of social stigmatization
Relative frequencies of perception of social stigmatization
are described in Table 4. The mean score for the perception
of social stigmatization towards patients with schizophre-
nia was 5.4 SD 1.86 (skewness = -1.11). The median was
6. A percentage of 10.1% had a score between 0 and 2,
31.8% had a score between 3 and 5, and 58.1% had a score
superior to 5.
Demographic variables
There was no statistical difference by age or sex in per-
ception of social stigmatization scores (Table 5). On the
item level, the only statistical differences found were that
older people consider that young men would be reluctant to
date a person with schizophrenia in a lower percentage than
younger groups [age group 1 (70.1%) vs. age group 3
(53.6%): Pearson v2[1] = 8.6, P = 0.003, age group 2
(73%) vs. age group 3 (53.6%): Pearson v2[1] = 13.4,
P \ 0.001, the comparison between age group 1 and age
group 2 showed no statistically difference: v2[1] = 1–23,
P = 0.26], and that women perceived that the opinion of
people with schizophrenia is considered less serious in a
significant higher percentage than men (74.2 vs. 67.3%
Pearson v2 [1] = 7.1, P = 0.005).
Mean scores were different according to levels of edu-
cational attainment (Table 5). Mann–Whitney post hoc
tests with Bonferonni’s correction (0.05/6 = 0.008)
revealed that there was a significant statistical difference
between the complete tertiary or university education
group with the elementary school education group and the
high school education group (Z = -4.01, P \ 0.001;
Z = -2.9, P = 0.003, respectively) There was no differ-
ence between mean scores by socioeconomic class
(Table 5).
Familiarity variables
People who lived with a person with schizophrenia or had
some kind of relationship with them as well as people who
worked in mental health did not have a different perception
of social stigmatization than the rest of the sample
(Table 5).
Table 4 Perception of social stigmatization (N = 1,254)
Most people … Yes N (%)
General Men Women
Prefer to hire another person before hiring a patient with schizophrenia 1,093 (87.2) 488 (87.1) 605 (87.3)
Would avoid hiring a patient with schizophrenia to take care of their children 1,189 (94.8) 529 (94.5) 660 (95.1)
Young women would be reluctant to date a person with schizophrenia 904 (72.1) 403 (72) 501 (72.3)
Young men would be reluctant to date a person with schizophrenia 886 (70.7) 398 (71.1) 488 (70.4)
Think less of a person who has been in a mental hospital 980 (78.1) 431 (77) 549 (79.1)
Would take the opinion of a person with schizophrenia less seriously 892 (71.1) 377 (67.3) 515 (74.2)
Feel that entering a mental hospital is a sign of personal failure 829 (66.1) 364 (65) 465 (67)
Table 3 Social distance towards people with schizophrenia
Would you… Yes N (%)
General Men Women
Be ashamed of having in your family somebody with schizophrenia? 121 (9.6) 54 (9.6) 67 (9.7)
Be afraid of talking with someone with schizophrenia? 86 (6.9) 33 (5.9) 53 (7.6)
Be disturbed having a neighbor with schizophrenia? 169 (13.5) 83 (14.8) 86 (12.4)
Be disturbed about working with someone with schizophrenia? 318 (25.4) 154 (27.5) 164 (23.6)
Have a friend with schizophrenia? 907 (72.3) 410 (73.2) 497 (71.6)
Marry someone with schizophrenia? 292 (23.3) 152 (27.1) 140 (20.2)
Soc Psychiat Epidemiol
123
After performing a multiple linear regression analysis
we observed that perception of social stigmatization score
was poorly predicted by demographic and familiarity fac-
tors (R2 = 0.01, F [8] = 2, P \ 0.001) being education
level the only significant predictor variable (b coeffi-
cient = 0.09; P = 0.002).
Relationship between variables
We calculated the association between the three scores
studied using Spearman rank correlation. After alpha cor-
rection (0.05/3 = 0.01) the following correlations were
significant: Knowledge was correlated with social distance
Table 5 Mean results of knowledge, social distance and perception of social stigmatization scores by demographic and familiarity variables
Knowledge Social distance Perception of social
stigmatization
Gender
Men 4.59 1.57 5.33
Women 4.75 1.61 5.45
Z = -1.5, P = 0.126 Z = -0.48; P = 0.63 Z = -1.23, P = 0.21
Age
18–30 4.41 1.38 5.30
31–64 4.75 1.68 5.48
[64 5.63 2.02 5.25
v2 (2) = 15.5, P \ 0.001 v2 (2) = 27.5, P \ 0.001 v2 (2) = 3, P = 0.21
Educational level
Incomplete elementary 2.75 1.25 5.68
Complete elementary 4.09 1.83 4.99
Complete high school 4.39 1.50 5.36
Complete university/tertiary 5.40 1.66 5.59
v2 (3) = 54.5, P \ 0.001 v2 (3) = 8.4, P = 0.03 v2 (3) = 18.4, P < 0.001
Socioeconomic class
Low 2.63 1.56 5.40
Low medium 3.67 1.87 5.37
Medium 5.03 1.48 5.40
High medium 5.19 1.80 5.46
High 4.33 3.00 4.66
v2 (4) = 94.6, P < 0.001 v2 (4) = 22.6, P \ 0.001 v2 (4) = 0.03, P = 1
Familiarity
Related with person with mental illness 5.35 1.48 5.33
Not related with person with mental illness 4.34 1.65 5.43
Z = -7.08, P \ 0.001 Z = -1.7, P = 0.08 Z = -1,1, P = 0.09
Related with people with sch 5.95 1.43 5.54
Not related with people with sch 4.52 1.61 5.38
Z = -6.6, P < 0.001 Z = -1.7, P = 0.07 Z = 1.8, P = 0.06
Living
Living with person with mental illness 5.43 1.52 5.44
Not living with person with mental illness 4.60 1.60 5.39
Z = -3.5; P < 0.001 Z = -0.02, P = 0.9 Z = -0.01, P = 0.9
Living with people with sch 6.51 1.72 5.41
Not living with people with sch 4.64 1.59 5.40
Z = -3.6; P < 0.001 Z = -0.8, P = 0.3 Z = -0.6, P = 0.5
Knowledge scores are 0–10 (higher scores reflect greater knowledge), social distance scores are 0–6 (higher scores reflect greater social distance),
perception of social stigmatization is 0–7 (higher scores reflect greater perception of social stigmatization)
Mann–Whitney tests are used for comparison between two variables. Kruskal–Wallis tests are used for comparison between more than two
variables
P \ 0.05 or P \ 0.001 are bolded
Soc Psychiat Epidemiol
123
with a small effect size (rs = -0.07, P = 0.01) and social
distance score was correlated with the perception of social
stigmatization score with a medium effect size (rs = 0.33,
P \ 0.001).
We performed subgroup analyses in those groups that
had higher knowledge scores: In subjects older than
64 years old (N = 82), in individuals that have some kind
of relationship with people with schizophrenia (N = 144)
and in those who live with patients with schizophrenia
(N = 29) the knowledge about the illness was not signifi-
cantly correlated with social distance (rs = -0.181,
P = 0.1, rs = 0.02, P = 0.7 and rs = -0.29, P = 0.1,
respectively).
Discussion
Our study found that knowledge about schizophrenia was
moderate compared with other international studies [48,
51], although methodological differences between studies
(face to face interview in our study vs. telephone survey)
could account for some of the differences found. More than
40% of the surveyed answered al least half of the knowl-
edge questionnaire correctly. Nevertheless, almost half of
the respondents still considered schizophrenia as a split
personality as in previous research [48], denoting an erro-
neous understanding of the name of the illness. It is pos-
sible that this misunderstanding is due to the metaphorical
use of this word on the media [18] or other cultural influ-
ences [43].
Less than 7% of respondents considered psychotherapy
as the only treatment for schizophrenia unlike other
countries, such as Germany and Canada, where more than a
third of the respondents considered that option [23, 48].
This is quite surprising given the significant role that
psychotherapy and clinical psychology have in Buenos
Aires [3]. The therapeutic use of medication was consid-
ered by 67% of the surveyed, in accordance with the
extended and accepted use of psychotropics among the
general population in Buenos Aires [31]. Respondents who
were older, more educated and directly related with people
suffering from schizophrenia were more likely to correctly
answer those questions focused on knowledge. It is difficult
to know if the higher level of knowledge of the elderly is
due to a potential greater degree of contact with people
with schizophrenia in the community, or due to a higher
level of informal training about this illness. Personal
experiences, anecdotal evidence and television and movies
account as sources of information for the general popula-
tion [26].
Almost 80% of the sample had less than one-third of
the maximum possible social distance score. This result
reveals a somewhat higher social distance than in Canada
and Germany [23, 48] but lower than in Turkey and
Nigeria [2, 50]. As in previous surveys [5, 23, 48] social
distance increased with higher closeness of the relation-
ship, meaning that there are intimate and private areas of
life where people is reluctant to let persons with mental
illness enter. The fact that one in four people would be
disturbed about working with a person with schizophrenia
shows the social barrier that rehabilitation programs face
to integrate patients to the job market. This result is in
concordance with a recent study that found that the
majority of Chilean businessmen believed that people
with schizophrenia are not able to perform adequately in
their jobs [17]. The result on job discrimination in our
study is surprisingly higher than in developed countries
[23, 48] in spite of the better outcome in illness course
seen in undeveloped countries [25]. A potential explana-
tion for this result could be that Buenos Aires is mainly
composed of middle class inhabitants, and members with
schizophrenia of this social class in undeveloped countries
tend to have a less favorable outcome than the rest of the
population [30].
Sex difference was only found in the marriage item:
women were more reluctant to marry a person with
schizophrenia than men. This finding was similar than in a
previous study [23]. It may be that, in order to marry,
women appreciate the work ability and the economic
potential of their partner more than men [16]. Higher age
was also associated with greater rejection of people with
schizophrenia. This observation has been made in other
studies [5, 8, 14, 23, 32, 38, 48]. We can speculate that
older people have a tendency to be more rigid and con-
servative on their ideas and beliefs, and this fact may guide
them to have more stigmatizing attitudes toward the people
with mental illness. Besides, their physical fragility may
cause them to be more afraid of the supposed violent
consequences of the patients0 illness. These findings sug-
gest that it might be beneficial to design specific anti-
stigma programs directed to the elderly.
Social distance of respondents who are familiar with
people with schizophrenia or work in mental health was
not lower than in the general population. This finding has
also been reported in some studies [7, 32, 48], but not in
others [1, 6, 19]. It is possible that a higher knowledge
about the illness which could potentially allow for a lower
social distance is counteracted by the difficulties of daily
interaction. The tendency of professionals to focus on
their patients’ deficits and not on their abilities [47] may
account for the similar level of public stigma seen in
mental health workers and suggests that anti-stigma pro-
grams directed to the mental health provider community
may be beneficial.
The perception of social stigmatization in our study
was high compared with other studies in developed
Soc Psychiat Epidemiol
123
countries [23, 24]. This could reveal an actual higher
discrimination towards people with schizophrenia in
Argentina, but also an overestimation of the stigmatiza-
tion. However, as was stated before, different assessment
methods between studies could account for the differences
found. Almost 80 percent of the population considered
that the opinion of a patient with schizophrenia is not
taken seriously compared with fifty percent of the German
sample [23]. In addition, almost 80% of the surveyed
affirmed that people would prefer to hire another person
before hiring a patient with schizophrenia, denoting again
the enormous difficulties to reintegrate patients in the
community.
Our sample did not show a higher rate of perception of
social stigmatizing among those persons that are related to
or live with people suffering schizophrenia, as it was
reported in a previous study [41]. As this perception was so
high among the general population a ceiling effect could be
considered for this negative finding.
Limitations
There are some limitations in our study that should be
taken in account when interpreting the results: although the
survey was done in public places and in almost all the
neighborhoods of the city, the over representation of
younger and more educated persons may reflect a selection
bias toward people that agreed to answer stigma questions.
In addition, the relative high percentage of persons with
mental health employment could account for this limita-
tion. Therefore, the generalization of these results should
be considered cautiously. This sample bias may account
also for the different levels of stigma noted in this study
compared to other international studies. Safety problems in
our country prevented us from conducting a random
household survey. It is also known that a face to face
interview could have increased the social desirability effect
[11]. A random telephone survey would have made the
sample more representative and, therefore, increase the
generalization of its results. It should be considered that
the measure of social distance reflects attitudes and not
actual behaviors, although it has been demonstrated that
there is a substantial association between them [27]. A way
to overcome the probable difference between the attitudes
reflected in this study and the actual behaviors is to also
study the discrimination perceived by the patients them-
selves. The concordance of the attitudes of the general
population and the discrimination perceived by the patients
and their relatives would confirm the results. Finally, the
dichotomizing of the variables may avoid more accurate
intermediate answers, but also of more arbitrary
interpretation.
Conclusions
Our study reveals that in Buenos Aires, although knowl-
edge about schizophrenia is similar to that in developed
countries, social distance towards people suffering from
schizophrenia is higher, and the perception of social stig-
matization is even greater. It seems that in order to
diminish discrimination we must consider other measures
besides education, such as increasing public anti-stigma
policies. Our study points out the need of specific cam-
paigns addressing the elderly, a group which showed less
tolerant views. Also, reducing the social distance held by
people living or working with persons suffering from
schizophrenia would potentially bring multiple benefits to
the quality of life of these patients.
References
1. Addison SJ, Thorpe SJ (2004) Factors involved in the formation
of attitudes towards those who are mentally ill. Soc Psychiatry
Psychiatr Epidemiol 39:228–234
2. Adewuya A, Makanjuola R (2005) Social distance towards peo-
ple with mental illness amongst Nigerian university students. Soc
Psychiatric Psychiatr Epidemiol 40:865–868
3. Alonso MM (2006) Los psicologos en la Argentina. Psicodebate
6. Psicologıa. Cult Soc 6:7–14
4. Association American Psychiatric (2000) Diagnostic and statis-
tical manual of mental disorders: 4th edn. revised. American
Psychiatric Association, Washington, DC
5. Angermeyer MC, Dietrich S (2006) Public beliefs about and
attitudes towards people with mental illness: a review of popu-
lation studies. Acta Psychiatr Scand 113:163–179
6. Angermeyer MC, Matschinger H, Corrigan PW (2004) Famil-
iarity with mental illness and social distance from people with
schizophrenia and major depression: testing a model using data
from a representative population survey. Schizophr Res 69(2–
3):175–182
7. Angermeyer MC, Matschinger H (1996) The effect of personal
experience with mental illness on the attitude towards individuals
suffering from mental disorders. Soc Psychiatry Psychiatr Epi-
demiol 31:321–326
8. Angermeyer MC, Matschinger H (1997) Social distance towards
the mentally ill: results of representative surveys in the Federal
Republic of Germany. Psychol Med 27:131–141
9. Berge M, Ranney M (2005) Self-esteem and stigma among per-
sons with schizophrenia: implications for mental health. Care
Manage J 6:139–144
10. Bogardus EM (1925) Measuring social distance. J Appl Soc
9:299–308
11. Bowling A (2005) Mode of questionnaire administration can have
serious effects on data quality. J Public Health 27:281–291
12. Breier A, Scheiber JL, Dyer J et al (1991) National Institute of
Mental Health longitudinal study of chronic schizophrenia. Arch
Gen Psychiatry 48:239–246
13. Brislin RW (1986) The wording and translation of research
instruments. In: Lonner WL, Berry JW (eds) Field methods in
cross-cultural research. Sage, Newbury Park, pp 137–164
14. Brockington IF, Hall P, Levings J, Murphy C (1993) The
community’s tolerance of the mentally ill. Br J Psychiatry
162:93–99
Soc Psychiat Epidemiol
123
15. Bullinger M, Alonso J, Apolone G et al (1998) Translating health
status questionnaires and evaluating their quality: the IQOLA
Project approach: International Quality of Life Assessment.
J Clin Epidemiol 51:913–923
16. Buss DM (1989) Sex differences in human mate preferences:
evolutionary hypotheses tested in 37 cultures. Behav Brain Sci
12:1–49
17. Chuaqui J (2005) El estigma en la esquizofrenia. Ciencias Soc
Online 2:45–66
18. Clement S, Foster N (2008) Newspaper reporting on schizo-
phrenia: a content analysis of five national newspapers at two
time points. Schizophr Res 98(1–3):178–183
19. Corrigan PW, Edwards AB, Green A et al (2001) Prejudice,
social distance, and familiarity with mental illness. Schizophr
Bull 27(2):219–225
20. Direccion General de Censo y Estadıstica (2008) Encuesta Anual
de Hogares de la Ciudad de Buenos Aires. Aspectos Demograf-
icos 2006, no. 14
21. Direccion General de Censo y Estadıstica (2008). Encuesta Anual
de Hogares de la Ciudad de Buenos Aires. Aspectos Educativos
2004–2005, no. 13
22. Ertugrul A, Ulug B (2004) Perception of stigma among patients
with schizophrenia. Soc Psychiatry Psychiatr Epidemiol 39:73–
77
23. Gaebel W, Baumann A, Witte A, Zaeske H (2002) Public atti-
tudes towards people with mental illness in six German cities. Eur
Arch Psychiatry Clin Neurosci 252:278–287
24. Griffiths KM, Nakane Y, Christensen H et al (2006) Stigma in
response to mental disorders: a comparison of Australia and
Japan. BMC Psychiatry 6:21
25. Harrison G, Hopper K, Craig T et al (2001) Psychotic illness: a
15- and 25-year international follow-up study. Br J Psychiatry
178:506–517
26. Jorm AF (2000) Mental health literacy: public knowledge and
beliefs about mental disorders. Br J Psychiatry 177:396–401
27. Krauss SJ (1995) Attitudes and the prediction of behavior: a
metanalysis of the empirical literature. Pers Soc Psychol Bull
21:58–75
28. Leckwart JF (1968) Social distance: an important variable in
psychiatric settings. Psychiatry 31:352–361
29. Lee PW, Lieh-Mak F, Wong MC et al (1988) The 15 year out-
come of Chinese patients with schizophrenia in Hong Kong. Can
J Psychiatry 43:706–713
30. Leff J, Warner R (2006) Why work helps: social inclusion of
people with mental illness. Cambridge University Press,
New York
31. Leiderman EA, Mugnolo JF, Bruscoli N et al (2006) Consumo de
psicofarmacos en la poblacion general de la ciudad de Buenos
Aires. Vertex Rev Arg de Psiquiat 17:85–91
32. Levav I, Shemesh A, Grinshpoon A et al (2004) Mental health-
related knowledge, attitudes and practices in two kibbutzim. Soc
Psychiatry Psychiatr Epidemiol 39:758–764
33. Link BG, Cullen F (1983) Reconsidering the social rejection of
ex-mental patients: levels of attitudinal response. Am J Commun
Psychol 11:261–273
34. Link BG, Cullen FT, Frank J et al (1987) The social rejection of
former mental patients: understanding why labels matter. Am J
Sociol 92:1461–1500
35. Link BG, Cullen FT, Struening E, Schrout PE, Dohrenwend BP
(1989) A modified labeling theory approach to mental disorders:
an empirical assessment. Am Soc Rev 54:400–423
36. Link BG, Struening EL, Rahav M et al (1997) On stigma and its
consequences: evidence from a longitudinal study of men with
dual diagnosis of mental illness and substance abuse. J Health
Soc Behav 38:177–190
37. Lysaker PH, Tsai J, Yanos P, Roe D (2008) Associations of
multiple domains of self-esteem with four dimensions of stigma
in schizophrenia. Schizophr Res 98(1–3):194–200
38. Magliano L, Fiorillo A, De Rosa C et al (2004) Beliefs about
schizophrenia in Italy: a comparative nationwide survey of the
general public, mental health professionals, and patients0 rela-
tives. Can J Psychiatry 49:322–330
39. Marwaha S, Johnson S (2004) Schizophrenia and employment.
Soc Psychiatry Psychiatr Epidemiol 39:337–349
40. Matas M, el-Guebaly, Peterkin N et al (1985) Mental illness and
the media: an assessment of attitudes and communication. Can J
Psychiatry 31:12–17
41. Phelan JC, Bromet EJ, Link BG (1998) Psychiatric illness and
family stigma. Schizophr Bull 24:115–126
42. Racenstein JM, Penn D, Harrow M et al (1999) Thought disorder
and psychosocial functioning in schizophrenia: the concurrent
and predictive relationships. J Nerv Ment Dis 187:281–289
43. Schomerus G, Kenzin D, Borsche J, Matschinger H, Angermeyer
MC (2007) The association of schizophrenia with split person-
ality is not an ubiquitous phenomenon: results from population
studies in Russia and Germany. Soc Psychiatry Psychiatr Epi-
demiol 42:780–786
44. Small R, Yelland J, Lumley J et al (1999) Cross-cultural research:
trying to do it better. 2. Enhancing data quality. Aust N Z J Public
Health 23:390–394
45. Stefani D (1985) Autoritarismo y actitud hacia la enfermedad
mental. Salud Ment 8(2):27–30
46. Stefani D (1979) Actitud hacia la enfermedad mental y nivel
socioeconomico. Acta Psiquiat Psicol Am lat 25:282–286
47. Strauss JS (2008) Prognosis in schizophrenia and the role of
subjectivity. Schizophr Bull 34:201–203
48. Stuart H, Arboleda-Florez J (2001) Community attitudes towards
people with schizophrenia. Can J Psychiatry 46:245–252
49. Stuart H (2008) Fighting the stigma caused by mental disorders:
past perspectives, present activities, and future directions. World
Psychiatry 7:185–188
50. Taskin EO, Sen FS, Aydemir O et al (2003) Public attitudes to
schizophrenia in rural Turkey. Soc Psychiatry Psychiatr Epi-
demiol 38(10):586–592
51. Thompson A, Stuart H, Bland RC et al (2002) Attitudes about
schizophrenia from the pilot site of the WPA worldwide cam-
paign against the stigma of schizophrenia. Soc Psychiatry Psy-
chiatr Epidemiol 37:475–482
52. Toledo Piza Peluso E, Blay SL (2004) Community perception of
mental disorders: a systematic review of Latin American and
Caribbean studies. Soc Psychiatry Psychiatr Epidemiol 39:955–
961
53. Walsh E, Buchanan A, Fahi T (2002) Violence and schizophre-
nia: examining the evidence. Br J Psychiatry 180:490–495
54. Wiersma D, Nienhuis FJ, Slooff CJ et al (1998) Natural course of
schizophrenic disorders: a 15-year follow-up of a Dutch inci-
dence cohort. Schizophr Bull 24:75–85
55. Wolff G, Pathare S, Craig T, Leff J (1996) Community attitudes
to mental illness. Br J Psychiatry 168:183–190
Soc Psychiat Epidemiol
123