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http://isp.sagepub.com/content/58/5/544The online version of this article can be found at:
DOI: 10.1177/00207640114136782012 58: 544 originally published online 9 August 2011Int J Soc Psychiatry
M. Economou, E. Louki, L. E. Peppou, C. Gramandani, L. Yotis and C. N. Stefanisschool students' attitudes to schizophrenia
ghting psychiatric stigma in the classroom: The impact of an educational intervention on seconda
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Economou et al. 545
choices about mental illness and hence can act as the first
step towards attitudinal and behavioural change (Corrigan,
2004b). Corrigan and Penn (1999) have shed light on this
strand of research by identifying four key components of
successful educational interventions: the provision of
personal information about the patient with mental illness;
a direct attack of myths; an increase in empathy levels bysimulation; and an in-depth discussion on the topic. In
addition, to increase the effectiveness of any anti-stigma
approach, including an educational one, the intervention
should target specific population groups (Corrigan, 2004a;
Thornicroft, 2006).
With regard to young population groups, converging
evidence has supported that school-based anti-stigma initi-
atives may constitute an effective vehicle for advancing
knowledge about mental illness and improving attitudes
towards the patients who suffer from it (Pinfold, Toulmin,
Thornicroft, & Huxley, 2003; Rickwood, Cavanagh, Leigh,
& Sakrouge, 2004; Schachter et al., 2008; Schulze, Richter-
Werling, Matschinger, & Angermeyer, 2003; Stuart, 2006).
Children and adolescents have emerged as a promising tar-
get group for anti-stigma interventions, because throughout
this developmental period attitudes to mental illness are
consolidated. Various studies have demonstrated that chil-
dren do not yet have a clear idea of what mental illness
denotes (Corrigan & Watson, 2007), and that the person-
ality traits that constitute the foundation for stereotype
endorsement are not well entrenched until adolescence
(Flavell, Miller, & Miller, 2001). Therefore, by altering
unfavourable and rejecting attitudes among children and
adolescents, one can prevent them from becoming adults
who hold traditional stereotypical beliefs about people withmental illness and hence stigmatize them. Furthermore,
addressing children and adolescents merits special atten-
tion in light of the high prevalence of psychiatric disorders
in this population (Schulze et al., 2003; Stuart, 2006).
Evidence from the World Health Organization (2005) sug-
gests that while one in five adolescents experiences a men-
tal disorder, only 20% of them will seek professional help
for fear of being labelled as mentally ill. This finding is
important given that many psychiatric disorders emerge
during adolescence, such as obsessive compulsive disorder
(Maggini et al., 2001) and schizophrenia (Thomsen, 1996).
In spite of the significance of this type of intervention,the literature on the effectiveness of anti-stigma initiatives in
children and adolescents is scarce (Schachter et al., 2008).
The limited number of studies on the topic have indicated
that prior to the intervention, the majority of students are
either unsure about the correctness of stereotypical views
about patients with psychiatric disorders or less rejecting
towards them in comparison to adults; with variables such
as gender and familiarity with mental illness playing a
prominent role in stigma endorsement (Corrigan et al., 2005;
Ng & Chan, 2002; Pinfold et al., 2003; Schulze et al., 2003;
Watson et al., 2004). In terms of effective interventions,
education has been shown to yield improvements of short
duration in attitudes towards mental illness in adolescents
(Ng & Chan, 2002; Schulze et al., 2003; Watson et al., 2004;
Williams & Pow, 2007). However, social distance measures,
which constitute the most widely used index of stigmatiza-
tion (Jorm & Oh, 2009), have been found to display the
greatest resistance to change upon completion of the edu-cational intervention (Pinfold et al., 2003; Schulze et al.,
2003). Recent evidence has indicated that when personal
contact with a patient with mental illness, either in vivo or in
a video, is added to education, attitudes towards patients are
improved and desired social distance from them is remark-
ably reduced (Chan, Mak, & Law, 2009; Schachter et al.,
2008; Stuart, 2006)
The anti-stigma programme, run by the University
Mental Health Research Institute, has designed and imple-
mented a series of anti-stigma interventions in adolescents
within the framework of World Psychiatric Association
Open the Doors global program against stigma and dis-
crimination because of schizophrenia. Due to the focus of
the programme on schizophrenia at the time (Economou,
Gramandani, Richardson, & Stefanis, 2005; Economou,
Richardson, Gramandani, Stalikas, & Stefanis, 2009), the
interventions addressed the stigma surrounding severe
mental illness in general and schizophrenia in particular.
The aim of the intervention was to advance students
knowledge about schizophrenia, to improve their attitudes
towards the patients who suffer from it and to reduce their
desired social distance levels. Consistent with this, the
intervention aimed to yield changes in all three dimensions
of stigma, namely knowledge, attitudes and behaviour
(Thornicroft, 2006); however, changes in the behaviourdimension were assessed indirectly by employing a social
distance measure, which constitutes a proxy of behavioural
intention. To achieve its aims, the initial intervention proto-
col incorporated a combined education and personal con-
tact strategy, in line with the literature underscoring its
effectiveness (Chan et al., 2009; Schachter et al., 2008;
Stuart, 2006). However, a number of objections and com-
plaints on the part of parents, school principals and teachers
necessitated changes in the protocol resulting in the elimi-
nation of the personal contact components. Therefore, in its
final form, the intervention was largely educational in
nature but it did entail some narratives of patients withschizophrenia read by a mental health professional. To opti-
mize the interventions effectiveness, its content was based
on Corrigan and Penns (1999) recommendations. In the
context of patient narratives, personal information about
the patient and his/her aftercare was provided to students,
the myths that surround schizophrenia were attacked one
by one, students empathic feelings towards patients were
enhanced by role-play exercises and an in-depth discussion
on the topic was conducted. Consistent with these, the pre-
sent study set the twofold aim of exploring high school
students beliefs, attitudes and desired social distance
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Economou et al. 547
students. The self-reported instrument comprised two parts,
one exploring beliefs and attitudes towards schizophrenia
and PwS, and another addressing the degree of desired
social distance from them. The beliefs and attitudes part
encompassed 11 items, rated on a four-point Likert scale
(1 = never, 4 = always), with some of them being nega-
tively phrased in order to avoid response bias (e.g. PwScan be creative). Similarly, the social distance section of
the instrument consisted of seven items, rated on a four-
point Likert scale (1 = definitely no, 4 = definitely yes),
with some of them being also negatively phrased in order to
avoid bias (e.g. Would you invite someone with schizo-
phrenia to your party?). For both sections, a composite
score was calculated by adding up the responses to all
items, after having reversed the negatively phrased items
(subtracting their rating from 5). For both composite scores,
higher values indicated more stereotypical beliefs and neg-
ative attitudes towards schizophrenia and PwS as well as a
greater desired social distance from them. A reliability
analysis utilizing Cronbachs indicated moderate internal
consistency for both composite scores (for beliefs, =
0.60.76 and for social distance, = 0.760.78).
Statistical analysis
For a descriptive analysis of students baseline beliefs,
attitudes and social distance answers, percentages of
pooled responses for each item were used. For the analysis
of associations between gender and familiarity with men-
tal illness on the one hand, and baseline beliefs, attitudes
and social distance measures on the other, two composite
scores were calculated: one for beliefs and attitudes andanother for social distance. A t test for independent sam-
ples was then used to reveal any differences. In order to
evaluate the short-term effect of the intervention on beliefs,
attitudes and social distance, the mean baseline score for
each item was compared to the mean post-intervention
score for the corresponding item by using a repeated
measures t test analysis. Similarly, to evaluate the long-
term effectiveness of the intervention, a pairwise ttest was
used between the baseline mean scores for each item and
its corresponding follow-up score. The rationale for con-
ducting item analysis in the study was to identify which
beliefs, attitudes and social interactions displayed thegreatest change and which displayed the least. In addition,
for the beliefs and attitudes section of the instrument, the
reliability analysis demonstrated wide variability in the
values of Cronbachs (range 0.60.76) and as a result of
this, analysis on a scale level was contentious and hence
was avoided. On the contrary, as social distance scales
have been empirically supported in terms of their psycho-
metric properties, the results pertaining to the social dis-
tance items were analysed on a scale level as well. The
effect of the intervention on the social distance composite
score was assessed using repeated measures ANOVA.
A multiple linear regression model on follow-up scores
was used in order to identify which factors could signifi-
cantly predict students follow-up results.
Results
The two groups (control and intervention) did not displaysignificant differences in terms of their basic demographic
variables, such as gender, age and personal acquaintance
with someone with serious mental illness (p > .05).
Baseline beliefs, attitudes and social distance
The two groups did not differ significantly with regard to
the distribution of their baseline responses to all items (p >
.05). To increase the statistical power of the analysis, data
were pooled in such a way that two categories were formed:
always/often and seldom/never for the beliefs and atti-
tudes section and definitely/probably yes and definitely/probably no for the social distance section.
The majority of students espoused the stereotypical
view of a PwS talking to him/herself or shouting in city
streets (80.1%). Similarly, a high percentage of students
reported that PwS always/often suffer from split or multi-
ple personalities (70.9%) or cannot work at regular jobs
(81.2%). Furthermore, one in two viewed PwS as danger-
ous (51.25% believed this is always/often the case) and
a public nuisance (50.5% answered always or often).
Interestingly, a relatively high percentage of the sample
held the positive view that PwS can be creative (67.15%),
can be successfully treated outside of the hospital in the
community (67.95%) and need prescription drugs to con-trol their symptoms (72.6%).
In terms of social distance items, the vast majority of
students would not fall in love with a PwS (86.8%) nor
would share their room with him/her during a school excur-
sion (81.85%). Furthermore, one in two would not invite a
PwS to their party (41.4% would probably/definitely do
so). Nonetheless, only 35.55% would be upset or disturbed
to be in the same class with a PwS, 46.75% would be afraid
to talk to him/her, while 70.5% would start a friendship
with him/her.
When composite scores were calculated, no gender
effect on beliefs, attitudes and social distance at baselineemerged (t= 0.3,p > .05 for the beliefs and attitudes section
and t= 0.89, p > .05 for the social distance section). By
contrast, previous contact with a person with a severe men-
tal illness was found to differentiate in a significant manner
the social distance scores at baseline (t= -2.57,p < .01).
Intervention effect
To evaluate the effectiveness of the intervention, students
answers before and after the workshop were compared for
the experimental and control groups separately.
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548 International Journal of Social Psychiatry 58(5)
Short-term effect: Upon completion of the intervention.
For the experimental group, beliefs and attitudes were
improved in all items but one (PwS can be successfully
treated without drugs using psychotherapy; Table 1) andthis cannot be explained by variables other than the inter-
vention, since the control group did not manifest the same
pattern of results (p > .05 for all items). Nonetheless, even
upon completion of the intervention, students still sub-
scribed to some negative stereotypes about PwS. Specifically,
the majority of students still believed that PwS can be seen
talking to themselves or shouting in city streets (mean score
= 3, which is higher than the neutral point 2.5 and closer to
the extreme always) and cannot hold a job in an open
labour market (mean score = 1.83, which is below the
neutral point 2.0 and closer to the extreme never).
Likewise for the social distance items, there was a
significant change in all items for the experimental group
(Table 2), whereas no significant changes were recorded for
the control group (p > .05 for all items). However, evenafter the intervention the mean score for the item Would
you fall in love with a PwS? was 1.88, which is below the
neutral point 2.0 and closer to the extreme definitely no.
Long-term effect: Follow-up. In order to address the long-
term effect of the intervention, the answers at the pre-inter-
vention and follow-up time points were compared. With
regard to students beliefs and attitudes to PwS, a
gradual worsening was observed from post-intervention
mean item scores to the corresponding follow-up scores.
Nonetheless, the statistical analysis revealed that follow-up
scores were significantly different from baseline scores on
Table 1. Mean item scores for beliefs and attitudes section at baseline, post-intervention and follow-up time points.
Beliefs and attitudes BaselineM (SD) Post-interventionM (SD) 12-month follow-upM (SD)
PwS suffer from split or multiplepersonalities
2.97 (0.69) 1.78 (0.95)* 2.5 (0.91)*
PwS tend to be mentally retarded or oflower intelligence
2.4 (0.83) 1.76 (0.82)* 2.18 (0.83)*
PwS hear voices telling them what to do 2.79 (0.77) 3.1 (0.85)* 2.86 (0.97)
PwS can be seen talking to themselvesor shouting in city streets
3.27 (0.69) 3 (0.78)* 3.04 (0.78)*
PwS are dangerous to the public 2.61 (0.82) 1.85 (0.83)* 2.05 (0.85)*
PwS are a public nuisance due topanhandling, poor hygiene or oddbehaviour
2.63 (0.9) 2.13 (0.98)* 2.37 (0.93)*
PwS can be successfully treated outsideof the hospital, in the community
3.01 (0.74) 3.32 (0.85)* 3.13 (0.7)
PwS can be successfully treated withoutdrugs using psychotherapy
2.6 (0.86) 2.75 (0.92) 2.70 (0.86)
PwS can work at regular jobs 1.7 (0.78) 1.83 (0.89)* 1.94 (0.86)*
PwS can be creative 2.85 (0.72) 3.45 (0.73)* 3.07 (0.75)*
Mean scores per item for the intervention group ranged from 1 (almost never) to 4 (almost always)*p< .01 difference compared to baseline
Table 2. Mean item scores for social distance section at baseline, post-intervention and follow-up time points.
Social distance BaselineM (SD) Post-interventionM (SD) 12-month follow-upM (SD)
Would you be afraid to talk to a PwS? 2.45 (0.91) 1.97 (0.91)* 2.28 (0.83)
Would you be upset or disturbed to be inthe same class with a PwS?
2.22 (1) 1.74 (0.8)* 1.85 (0.86)*
Would you start a friendship with a PwS? 2.95 (0.91) 3.15 (0.92)* 2.72 (0.89)
Would you invite a PwS to your party? 2.22 (0.9) 2.64 (0.94)* 2.44 (0.89)*
Would you feel embarrassed or ashamed
if your friends knew that someone in yourfamily had schizophrenia?
2.17 (1.11) 1.93 (1.12)* 2.08 (1.04)
Would you share your room on a schoolexcursion with a PwS?
1.72 (0.87) 2.35 (0.98)* 1.93 (0.85)*
Would you fall in love with a PwS? 1.49 (0.81) 1.88 (1)* 1.73 (0.92)
Mean scores per item for the intervention group ranged from 1 (definitely no) to 4 (definitely yes)*p < .01 difference compared to baseline
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Economou et al. 549
all items apart from two (PwS hear voices and PwS can be
successfully treated outside the hospital, in the community),
lending support to the long-term effectiveness of the inter-
vention. Concerning desired social distance from PwS, of the
seven items of the section, significant differences between
baseline and follow-up measures emerged for only three:
being classmates with a PwS, inviting him/her to a party and
sharing a room in a school excursion. For the remaining
items, the improvement observed at post-intervention was
not maintained. For the control group, no significant differ-
ences were observed between the pre-intervention and fol-
low-up measures for any item (p > .05).
When social distance was analysed on a scale level, a
repeated measures ANOVA with post hoc comparisons
using the Bonferroni correction revealed a significant dif-
ference between the baseline and post-intervention social
distance scores (M = 18.36, SD = 2.46 and M = 15.63,SD = 2.67, respectively), indicating a positive short-term
effect of the intervention; however, no significant differ-
ence was discerned between the baseline and the follow-up
scores (follow-up M= 17.96, SD = 2.23), indicating that
one year after the intervention, the students returned to their
baseline social distance levels (Figure 1).
Positive baseline scores and female gender were the
only two variables that predicted positive attitudes and
lower social distance scores at follow-up (R2 = 5.1%,F=
2.79,p < .05 for beliefs and attitudes composite score and
R2 = 20.1%, F= 11.41,p < .001 for social distance com-
posite score).
Discussion
The findings of the present study lend support to the imper-
ative need for developing effective anti-stigma interven-
tions targeting children and adolescents. Prior to receiving
any intervention, students were found to hold stereotypical
beliefs and rejecting attitudes towards PwS. The majority
of them espoused the belief that PwS are dangerous, cannot
work, speak to themselves or shout in city streets, suffer
from split personality and constitute a public nuisance. A
similar pattern of results has been recorded in the adult
population in Greece (Economou, Gramandani et al., 2005;
Economou et al., 2009). In spite of dissimilarities in the
sampling methods between the current study and those
carried out in adults, one can observe that adults are more
stigmatizing and negative towards PwS. Among the adoles-
cents, 51.25% held the view that PwS are dangerous in con-
trast to 70.1% of adults, after controlling for urbanruraldifferences. Similarly, 50.5% of adolescents were found to
deem PwS a public nuisance, while this figure is 62.9% in
adults. This finding is consistent with other studies that
have indicated that adolescents hold more favourable
attitudes than adults to people with mental illness (Schulze
et al., 2003; Watson et al., 2004).
Comparing the findings of the present study to those in
other countries, the young population in Greece appears to
be very distancing towards PwS. Schulze et al. (2003)
report that only 6.5% of students (average percentage
between the experimental and control group) stated that
they would be afraid to talk to a PwS, a rate that reaches
as high as 46.75% in our sample. Furthermore, while in
Germany, 20.5% of students admitted that they could fall in
love with a PwS, in Greece the rate is slightly lower, i.e.
13.2%. Interestingly, while adolescents in Greece express
greater desire for social distance from PwS in comparison
to their counterparts in Germany, the difference between
the two countries is more striking in items concerning
superficial encounters with the patient. In particular, the
difference in percentages between the two countries with
regard to the item Would you be afraid to talk to a PwS?
reaches 26.75%. Adolescents high levels of stigmatization
against PwS in Greece may be attributed to the Greek ori-
gin of the word schizophrenia and the strongly stigmatiz-ing media portrayals of PwS in the country (Economou,
Kourea et al., 2005). In Greek society the term schizophre-
nia is linked to fear and devastation and even mental health
professionals are avoiding its use by replacing it with that
of psychosis. Therefore, it is not surprising that while
most of the adolescents are oblivious to what the word
denotes, based on its literal meaning (i.e. split mind), they
usually speculate that the term is germane to a split person-
ality or a fragmented mind, both of which are mainly
associated with the traits of violence, dangerousness and
unpredictability (Economou et al., 2009). Furthermore,
adolescents in Greece are continuously exposed to stigma-tizing portrayals of PwS in the media, especially on TV and
at the cinema. An illustration of this point is the film Texas
Chainsaw Massacre, which has been repeatedly broadcast
on TV and in the cinema but which in Greece was released
as The Schizophrenic Killer with the Chainsaw. The very
stigmatizing Greek title capitalized on the association
between a schizophrenic patient and a serial killer in lay
peoples mind and therefore strengthened the stereotype of
dangerousness pertaining to PwS. It is noteworthy that
during the anti-stigma intervention when students were
asked about their sources of information with regard
to severe mental illness, the majority identified TV as
1
3
5
7
9
11
13
15
17
19
Baseline Post-intervenon 12-month follow-up
Comp
ositescore
Social distance
Figure 1. Differences in social distance composite scoresacross the three time points of the study.
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550 International Journal of Social Psychiatry 58(5)
their primary source and spontaneously referred to The
Schizophrenic Killer with the Chainsaw.
Compared to the literature that points towards gender
and familiarity with mental illness as factors that play a
prominent role in stigma endorsement, the present study
found no gender effect for baseline measures but a signifi-
cant impact of personal experience with mental illness. Theinfluence of gender on beliefs and attitudes to people with
mental illness has yielded conflicting results, with some
studies reporting that girls are more positive towards the
patients (Ng & Chan, 2002; Williams & Pow, 2007) and
some others failing to find a significant difference (Schulze
et al., 2003). Similarly, familiarity with mental illness has
been found to be associated with both more positive (Pinfold
et al., 2003) and more negative attitudes (Corrigan et al.,
2005). An interesting finding of the study was that only
female gender and baseline scores could predict follow-up
scores. While this is in line with the findings of an earlier
study (Pinfold et al., 2003), it is surprising that personal
experience with mental illness had a non-significant contri-
bution to the model. A possible explanation for this is the
diversity in the intensity of familiarity, which can vary from
a person watching TV portrayals of mental illness to having
a distant or a close relative suffering from a psychiatric dis-
order (Corrigan, Backs-Edwards, Green, Lickey-Diwan, &
Penn, 2001). It is therefore plausible that the educational
intervention increased students familiarity with mental ill-
ness and as a result of this, the differences that emerged at
baseline were compensated for at follow-up.
In terms of the effectiveness of the educational interven-
tion in modifying beliefs, attitudes and desired social dis-
tance from PwS, immediately upon its completion and at a12-month follow-up, the results that emerge support the
existing literature. In line with other studies (Ng & Chan,
2002; Schulze et al., 2003; Watson et al., 2004), the educa-
tional intervention was found to have a positive impact as
indicated by an improvement in attitudes and a remarkable
decrease in the frequency of stereotypical beliefs and in the
degree of desired social distance. With regard to the follow-
up results, the picture is more diverse. On the one hand, sig-
nificant improvements in adolescents beliefs and attitudes
after the intervention were largely maintained 12 months
after its completion. On the other, the improvement recorded
on the social distance items upon completion of the inter-vention was not maintained at follow-up, where students
almost returned to their baseline answers. In line with
Pinfold et al. (2003), it appears that social distance is more
resistant to change than other measures of stigmatization
and possibly necessitates a different approach for targeting
it. The intervention of the present study was brief and lacked
a personal contact component. As a result, an anti-stigma
intervention aiming at decreasing adolescents desired social
distance from PwS should consider involving patients and
allow for an interaction between them and the adolescents.
Furthermore, this intervention should be longer and con-
stantly delivered throughout the developmental period of
stereotype formation and consolidation. In this way, even if
adolescents are exposed to stigmatizing portrayals of people
with mental illness, in the media for example, their personal
contact with a number of PwS in the classroom coupled with
the appropriate education will enable them to stand critically
towards the vehicles that perpetuate the stigma attached to
mental illness. Health promotion programmes, like thoseimplemented at the participating schools, should become an
integral part of the high school curriculum and should be
delivered throughout school years.
Limitations
The major shortcoming of the present study was its inabil-
ity to extrapolate its findings to a representative sample of
adolescents throughout the country. The sample was
restricted to urban areas and only schools with a health pro-
motion programme in their curriculum took part. Given
that the preponderance of psychiatric stigma in Greek
urban areas has been found to be lower compared to rural
areas (Economou et al., 2009) and that students from
schools with a health promotion programme in their cur-
riculum are possibly more tuned and sensitized to issues of
health, stigma endorsement might have been stronger if a
more diverse sample was attained. This assumption is
further supported by the opposition expressed by many
schools to deliver any kind of intervention related to severe
mental illness to their students. In Greece, talking about
severe mental illness, and especially about schizophrenia,
to students is still a major taboo and demonstrates further
how entrenched psychiatric stigma is in the Greek culture.
Therefore, a future study aiming at broadening its recruit-ment scope would cast light on adolescents degree of
stigma endorsement and subsequently on the potential of
an anti-stigma intervention to fight it.
Acknowledgements
The authors would like to express their gratitude to Dimitris
Kolostoumpis, psychiatrist, and Maria Charitsi, psychologist,
University Mental Health Research Institute, for their valuable
contribution to the implementation of the study, as well as to
Anastassios Stalikas, Professor of Psychiatry, Panteion University,
for his contribution to the analysis of the results.
Funding
This research was conducted within the framework of the
Greek Programme against Stigma and Discrimination because
of Schizophrenia, whose major sponsor was the National Bank of
Greece.
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