Psychological Services 2014, Vol. 11, No. 1, 105–113

In the public domain DOI: 10.1037/a0032780

Endorsed and Anticipated Stigma Inventory (EASI): A Tool for Assessing Beliefs About Mental Illness and Mental Health Treatment Among Military Personnel and Veterans Dawne Vogt

Brooke A. L. Di Leone and Joyce M. Wang

National Center for Posttraumatic Stress Disorder, VA Boston Healthcare System, Boston, Massachusetts and Boston University School of Medicine

National Center for Posttraumatic Stress Disorder, VA Boston Healthcare System, Boston, Massachusetts

Nina A. Sayer

Suzanne L. Pineles

Minneapolis VA Health Care System, Minneapolis, Minnesota and University of Minnesota, Minneapolis

National Center for Posttraumatic Stress Disorder, VA Boston Healthcare System, Boston, Massachusetts and Boston University School of Medicine

Brett T. Litz Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System, Boston, Massachusetts and Boston University School of Medicine Many military personnel and veterans who would benefit from mental health treatment do not seek care, underscoring the need to identify factors that influence initiation and retention in mental health care. Both endorsed and anticipated mental health stigma may serve as principal barriers to treatment seeking. To date, most research on mental health stigma in military and veteran populations has relied on nonvalidated measures with limited content coverage and confounding in the assessment of different domains of mental health stigma. This article describes the development and psychometric evaluation of the Endorsed and Anticipated Stigma Inventory (EASI), which was designed to assess different dimensions of stigma-related beliefs about mental health among military and veteran populations. Findings based on a national sample of U.S. veterans deployed in support of Operation Enduring Freedom (OEF) in Afghanistan or Operation Iraqi Freedom (OIF) in Iraq suggest that the EASI is a psychometrically sound instrument. Specifically, results revealed evidence for the internal consistency reliability, content validity, convergent and discriminant validity, and discriminative validity of EASI scales. In addition, confirmatory factor analysis results supported the proposed factor structure for this inventory of scales. Keywords: stigma, barriers to care, VA health care use, veterans, military

Servicemembers are at risk for a range of mental health problems due to their potential exposure to traumatic events during deployment. For example, findings indicate that a substantial minority of servicemembers deployed in support of the recent wars in Afghanistan and Iraq report symptoms consistent with posttraumatic stress disorder (PTSD), depression, and alcohol abuse after returning from deployment (Hoge et al., 2004; Kang & Hyams,

2005; Lapierre, Schwegler, & LaBauve, 2007; Milliken, Auchterlonie, & Hoge, 2007). Despite the relatively high availability of free or low-cost mental health services in both military and Department of Veterans Affairs (VA) health care settings, many servicemembers and veterans who might benefit from treatment do not make use of available mental health services. For example, in a national sample of veterans deployed in support of Operation

This article was published Online First November 25, 2013. Dawne Vogt, Women’s Health Sciences Division, National Center for Posttraumatic Stress Disorder, VA Boston Healthcare System, Boston, Massachusetts, and Department of Psychiatry, Boston University School of Medicine; Brooke A. L. Di Leone and Joyce M. Wang, Women’s Health Sciences Division, National Center for Posttraumatic Stress Disorder, VA Boston Healthcare System; Nina A. Sayer, Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, and Departments of Medicine and Psychiatry, University of Minnesota, Minneapolis; Suzanne L. Pineles, Women’s Health Sciences Division, National Center for Posttraumatic Stress Disorder, VA Boston Healthcare System and Department of Psychiatry, Boston University School of

Medicine; Brett T. Litz, Massachusetts Veterans Epidemiology Research and Information Center, VA Boston Healthcare System and Department of Psychiatry, Boston University School of Medicine. This research was supported, in part, by a Department of Veterans Affairs Health Sciences Research and Development Service grant (DHI 06-225-2; Gender, Stigma, and Other Barriers to VHA Use for OEF/OIF Veterans; Principal Investigator: Dawne Vogt, PhD). Correspondence concerning this article should be addressed to Dawne S. Vogt, PhD, National Center for Posttraumatic Stress Disorder (116B-3), VA Boston Healthcare System, 150 South Huntington Avenue, Boston, MA 02130. E-mail: [email protected] 105

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Enduring Freedom (OEF; Afghanistan) or Operation Iraqi Freedom (OIF; Iraq), nearly half (47%) of individuals with probable posttraumatic stress disorder (PTSD) or major depression had not received any mental health care in the previous year and only 30% of those who had initially sought care reported having received a minimally adequate amount of care (Schell & Marshall, 2008). Consequently, it is important for administrators, decision-makers, leaders, and clinicians to identify and understand the factors that influence initiation and retention in mental health treatment among military and veteran populations. A review of the broader literature suggests two key facets of stigma that may influence treatment seeking. The first facet, referred to as endorsed stigma, is a key component of the self-stigma process that reflects the extent to which an individual has incorporated negative beliefs about the stigmatizing attribute (in this case, beliefs about mental illness and mental health treatment) into his or her own personal belief system (Corrigan & Rao, 2012; Link, 1987). The second facet, which draws from Corrigan and colleagues’ extensive body of work on public stigma related to mental illness (e.g., Corrigan, 2004; Corrigan & Rusch, 2002) and is referred to as anticipated stigma, reflects the extent to which an individual anticipates that he or she will be devalued or discredited by others in the community for having the stigmatized attribute (Earnshaw & Chaudoir, 2009; Earnshaw & Quinn, 2012; Markowitz, 1998). Although the military and veteran literature on mental health stigma is somewhat more limited than the broader civilian literature, there is reason to believe that stigma may be an especially powerful deterrent to service use among military and veteran populations. Specifically, it has been suggested that the high value placed on competence, confidence, and “emotional toughness” in the military may contributed to increased stigma in these populations (Nash, Silva, & Litz, 2009; Sayer et al., 2009). Moreover, the military includes a large proportion of young men, a group that has been found to be especially uncomfortable with acknowledging mental health problems and seeking care (Addis & Mahalik, 2003; Greene-Shortridge, Britt, & Castro, 2007; Mojtabai, Olfson, & Mechanic, 2002; Porter & Johnson, 1994). Despite the potential relevance of both forms of stigma, research on military and veteran populations has focused nearly exclusively on anticipated stigma as a barrier to care, paying far less attention to the role of self-stigma in service use (Vogt, 2011). The lack of research on this topic may be accounted for, at least in part, by the lack of validated measures designed to assess different components of self-stigma that are relevant for these populations. As a consequence, most military and veteran research to date has relied on brief, nonvalidated measures that do not provide a broad assessment of stigma-related barriers to care or that confound the assessment of different stigma components within a single scale (Vogt, 2011). Another limitation is the lack of scales that assess stigma independent of its perceived impact on service use. Findings based on measures that require respondents to evaluate the impact that stigma has on their service use, such as the widely used Perceived Stigma and Barriers to Care for Psychological Problems scale (Britt, 2000), are important in their ability to highlight the extent to which servicemembers and veterans perceive stigma as a barrier to care. However, some individuals may not feel comfortable acknowledging or not even realize the role that their own or others’ biases about mental illness play in their willingness to seek

mental health care (Vogt, 2011). Therefore, the field would also benefit from the availability of measures that address perceptions of stigma independent of its perceived impact on treatment seeking. To address this gap, we developed and validated an instrument that assesses a broad range of mental health beliefs that may have implications for servicemembers’ and veterans’ use of mental health care. Specifically, this instrument, called the Endorsed and Anticipated Stigma Inventory (EASI) builds on prior conceptualizations of stigma put forth in the literature and addresses both personal beliefs about mental illness and mental health treatment (i.e., endorsed stigma) and concerns about being stigmatized by others for having a mental health problem (i.e., anticipated stigma). In the instrument development phase (Part 1), we defined the stigma constructs that were the focus of this project and operationalized these constructs via initial item development. In Part 2, we examined the item and scale characteristics of the resulting scales. Part 3 was an examination of evidence for convergent and discriminant validity, as well as the smaller literature on mental health stigma in discriminative validity. Part 4 was an examination of the factor structure of the instrument using confirmatory factor analyses.

Method and Results Part 1: Instrument Development Defining the target construct and its content domains. We used a rational approach to test construction that emphasized content validity (Haynes, Richard, & Kubany, 1995; Jackson, 1971; Nunnally & Bernstein, 1994). Our first step in the development of the EASI was to clearly define the core components of the targeted stigma constructs and elaborate on their content domains. Our initial conceptualization of stigma-related beliefs about mental illness and mental health treatment in military and veteran populations drew from the broader literature on stigma (e.g., Cooper, Corrigan, & Watson, 2003; Corrigan, 2004; Corrigan & Rusch, 2002; Earnshaw & Chaudoir, 2009; Earnshaw & Quinn, 2012; Leaf, Bruce, & Tischler, 1986; Link & Phelan, 2001; Mansfield, Addis, & Courtenay, 2005; Sirey et al., 2001), as well as the more limited literature on mental health stigma among members of the military and veterans (e.g., Britt, 2000; Britt et al., 2008; GreeneShortridge et al., 2007; Pietrzak, Johnson, Goldstein, Malley, & Southwick, 2009). Synthesizing what have largely been separate research areas, we identified three potential components of endorsed stigma that may be especially salient for military and veteran populations. These components include: (a) beliefs about mental illness (Brown, 2008; Corrigan, Lickey, Campion, & Rashid, 2000; Day, Edgren, & Eshleman, 2007; Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999); (b) beliefs about mental health treatment (Leaf et al., 1986; Pirkis, Blood, Francis, & McCallum, 2006); and (c) beliefs about help-seeking for mental health problems (Mansfield et al., 2005; Ojeda & Bergstresser, 2008; Perlick & Manning, 2006; Waldron, 1997). As conceptualized in this measure, content domains within the beliefs about mental illness construct reflect beliefs about the character and competence of people with mental health problems, as well as one’s level of comfort interacting with people with mental illness. Content domains in the beliefs about mental health

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treatment construct include beliefs about talk therapy, medication, and mental health providers. Content domains in the beliefs about help-seeking construct include beliefs about the legitimacy of seeking help for mental health problems, as well as level of comfort with being in the “patient” role. Based on our review of this literature, we identified two general components of anticipated stigma related to mental health problems: (a) concern about stigma from loved ones, and (b) concern about stigma in the workplace. Content domains within the concern about public stigma from loved ones construct reflect individuals’ beliefs about the consequences of having a mental health problem for family members’ and friends’ level of comfort being around them and perceptions of their character and competence. Content domains within the concern about stigma in the workplace construct reflect individuals’ beliefs about the consequences of having a mental health problem for supervisors’ and coworkers’ level of comfort being around them and perceptions of their character and competence, as well as potential career consequences. Although concerns about stigma from loved ones are likely to be relevant for both current and former military personnel, concerns about mental health stigma in the workplace may be an especially salient barrier to care for current military personnel given the negative consequences that having a mental health problem may have on servicemembers’ military careers. Item development. Guided by the above definitions, and with ongoing reference to the broader literature, we developed an initial pool of items to reflect the content of each of these core components: (a) beliefs about mental illness, (b) beliefs about mental health treatment, (c) beliefs about treatment-seeking, (d) concerns about stigma from loved ones, and (e) concerns about stigma in the workplace. Items were framed as statements (e.g., “If I had a mental health problem and family/friends knew about it, they would think less of me”) and a 5-point Likert-type response format, ranging from 1 (strongly disagree) to 5 (strongly agree) was selected to allow respondents to indicate their level of agreement with each statement. No reverse-scored items were included, but positively phrased filler items (e.g., “If I had a mental health problem and family/friends knew about it, they would be supportive of me”) were included to reduce negativity bias. Scales were scored so that higher scores were indicative of greater stigma in each of the domains assessed in this inventory of scales. A table of specifications (Aiken, 1994) was developed to identify key domains within each component and aid in the orderly construction of item statements or questions across content areas. More specifically, different aspects of each component were identified, and items were written to systematically represent each content domain. The initial item sets along with the formal definition from which they were derived were reviewed by content and psychometric experts.

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Experts were asked to provide judgments regarding the content saturation of each item with respect to its content domain and to identify items that were confusing, poorly written, or had overlapping content. In cases where redundancy was identified, the item that was judged as most comprehensible and concise was retained. The end result of these steps was a newly refined pool of eight items per component, all clearly expressed and heavily saturated with the desired content. Given that military personnel are typically required to have at least a high school diploma, items were targeted to a high school grade level. An examination of the scale’s readability confirmed that all scales were appropriate for use with samples that have completed at least a ninth-grade education. Specifically, the Flesch-Kincaid Grade Level score (Flesch, 1949) was 7.2 for the Beliefs about Mental Illness scale, 8.4 for the Beliefs about Mental Health Treatment scale, 6.7 for the Beliefs about Treatment Seeking scale, 8.3 for the Concerns about Stigma from Loved Ones scale, and 9.1 for the Concerns about Stigma in the Workplace scale.

Part 2: Initial Item and Scale Analyses Using data generated from a national mail survey of OEF/OIF veterans, we first calculated frequency distributions and examined skewness and kurtosis for all items in the EASI. Next, we computed classical-test-theory-oriented item and scale characteristics (Aiken, 1994; Anastasi, 1988; Nunnally & Bernstein, 1994), with the goal of identifying any items that detracted from reliability and should be considered for elimination. Once item sets were finalized, means, standard deviations, and ranges were calculated for each scale (see Table 1). Participants. The emphasis in instrument development is to achieve a sample that has broad dispersion on the attributes that are the focus of the psychometric inquiry and ample representation of the kinds of persons for whom the instrument is intended (Nunnally & Bernstein, 1994). Potential participants were randomly selected from a Defense Manpower Data Center (DMDC) roster of all U.S. OEF/ OIF veterans who had experienced a deployment in support of either OEF or OIF, and were separated from military service at the time of the survey. All participants had returned from deployment between January 2007 and January 2009. To allow for gender-stratified analyses, the sample was stratified on gender (50% men, 50% women). A modification of the Dillman, Smyth, and Christian (2009) mail survey procedure was used for data collection, involving up to five contacts and a $20 prepaid gift card incentive in the first mailing of the survey. Of 2,950 potential participants, 461 could not be located and 17 responded to indicate that they were ineligible for the study (i.e., not OEF/OIF veterans). Among the remaining 2,472 individuals believed to have received the survey, 707 returned completed surveys for a response rate of 29%. We compared survey responders with nonre-

Table 1 Item and Scale Characteristics of the EASI Variable

n

Mean

SD

Range

Alpha

Beliefs about mental illness Beliefs about mental health treatment Beliefs about treatment seeking Concerns about stigma from loved ones Concerns about stigma in the workplace

677 676 681 672 679

18.13 19.43 21.17 18.56 23.81

5.65 5.43 6.85 7.59 7.56

8–34 8–37 8–40 8–39 8–40

.86 .84 .86 .92 .93

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sponders on demographic and military characteristics drawn from DMDC data to explore potential nonresponse bias. Overall, findings revealed few differences and those differences that were observed were generally small and unlikely to influence the specific associations under examination in this study. Differences between responders and nonresponders were small with regard to gender (Cramer’s ␾ ⫽ ⫺0.11), age (r ⫽ .190) race (Cramer’s ␾ ⫽ ⫺0.041), military rank (Cramer’s V ⫽ 0.146), education (Cramer’s ␾ ⫽ 0.187), marital status (Cramer’s ␾ ⫽ ⫺.071), military branch (Cramer’s V ⫽ 0.079), and duty status (Cramer’s ␾ ⫽ 0.005). Of the 707 respondents who provided completed surveys, 702 veterans who had returned their surveys prior to the initiation of this study were included in the current analyses. The sample was composed of 57% women and 43% men, and was primarily Caucasian (66%), with 16% identifying as African American. The mean age was 37.52 (SD ⫽ 9.99), and 40% of participants reported having a college degree. Approximately 79% were deployed from Active Duty and 21% were from the National Guard or Reserve components. Veterans from all branches of service were included: Army (50%), Air Force (24%), Navy (18%), and Marines (8%). Further details about this sample and the methodology are available from the first author. Results. Calculation of frequency distributions and examination of skewness and kurtosis in the full sample revealed no problems with dispersion on these items. Thus, we next examined estimates of internal consistency reliability and associated statistics for each scale. As indicated in the last column of Table 1, internal consistency reliability estimates for all scales exceeded .80 and were, therefore, considered acceptable. Item-total correlation values were also all acceptable, with values of at least .40 for all items within each scale, exceeding the minimum threshold for acceptability (i.e., .30; Nunnally & Bernstein, 1994). Specifically, item-total correlation values ranged from .47 to .75 for the Beliefs about Mental Illness scale (average value ⫽ .61), .43 to .70 for the Beliefs about Mental Health Treatment Scale (average value ⫽ .58), .46 to .71 for the Beliefs about Treatment Seeking scale (average value ⫽ .61), .66 to .80 for the Concerns about Stigma from Loved Ones scale (average value ⫽ .72), .60 to .84 for the Concerns about Stigma in the Workplace scale (average value ⫽ .76). Together, these findings provide evidence for the internal consistency reliability of the scales included in the EASI.

Part 3: Evidence for Validity Having created a content-saturated and internally consistent inventory of endorsed and anticipated stigma scales (see Appendix for the 40-item EASI), we next turned attention to examining evidence for the validity of this measure based on the same sample of OEF/OIF veterans. Associations among the three endorsed stigma scales and two anticipated stigma scales were examined to confirm their convergent validity. Associations between the endorsed and anticipated scales were examined to confirm their discriminant validity. Further evidence of discriminant validity was sought in terms of the association between these scales and a measure of social desirability. A final set of analyses was conducted to examine the discriminative validity of these scales with respect to mental health symptomatology, as it is well-established that individuals with mental health problems report more stigma-related concerns than those without mental health problems (e.g., Hoge et al., 2004). Specifically, analyses examined

whether individuals with and without probable PTSD, depression, and alcohol abuse differed on the stigma scales.

Additional Measures Marlowe-Crowne Social Desirability Scale (Crowne & Marlowe, 1960). A 13-item instrument (␣ ⫽. 84) was used to measure an individual’s tendency to describe himself/herself favorably or in a socially desirable manner. Scores were computed as the number of item responses in the keyed direction based on a true/false like response like response format. Higher scores indicate more social desirability. Sample items are “I have never intensely disliked anyone,” “I sometimes feel resentful when I don’t get my way,” and “There have been occasions when I took advantage of someone” (reverse scored). The estimate of internal consistency reliability for this scale was .79 in the current sample. PTSD Checklist–Military Version (PCL; Weathers, Litz, Herman, Huska, & Keane, 1993). The PCL was used to assess posttraumatic stress symptomatology related to stressful deployment experiences. The 17 items are directly adapted from the Diagnostic and Statistical Manual of Mental Disorders (DSM–IV; American Psychiatric Association, 1994) to assess reexperiencing, avoidance and emotional numbing, and hyperarousal symptoms. Respondents were asked to rate how much they have been bothered by each symptom in the past 6 month. Coefficient alpha was .97 in the current sample. Based on commonly used criteria for classifying probable PTSD among OEF/OIF veterans (Tanielian & Jaycox, 2008), those who had a minimum score of 50 (139 participants, 21% of total sample) were identified as having probable PTSD. Beck Depression Inventory–Primary Care (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). An adapted version of the 7-item Beck Depression Inventory-Primary Care was used to index depression symptoms (Beck, Steer, Ball, Ciervo, & Kabat, 1997). This measure consists of seven statements extracted from the original Beck Depression Inventory (Beck et al., 1961) but with a variation in the response format; unlike the original Beck instrument, each item is rated on a 5-point scale, with anchors ranging from 1 ⫽ strongly disagree to 5 ⫽ strongly agree. Sample items include “In the last 6 months, I have felt like a failure,” and “In the last 6 months, I have had thoughts of killing myself.” Scores on the original Beck Depression Inventory have correlated well with clinicians’ judgments of depression intensity (Beck, Steer, & Garbin, 1988). The coefficient alpha for this brief form of the measure is .91. The standard, empirically tested cut-off for the BDI-PC is a score of 4 for maximum clinical efficiency, specificity, and sensitivity (Beck et al., 1997; Steer, Cavalieri, Leonard, & Beck, 1999). Based on a commensurate cut-off to the BDI-PC’s score of 4, those who endorsed a 4 or greater on at least four of the seven items (263 participants, 39%) were classified as having probable depression. CAGE. The CAGE (Ewing, 1984) is a 4-item questionnaire that assesses the presence of clinically significant alcohol use. A correlation of .89 has been shown between CAGE scores and diagnoses when using the dichotomous, two-item cutoff method for scoring (Bradley, Kivlahan, Bush, McDonell, & Fihn, 2001). Coefficient alpha was .68 in the current sample. Based on commonly used criteria for classifying probable alcohol abuse (Buchsbaum, Buchanan, Centor, Schnoll, & Lawton, 1991), those who had a minimum score of 2 (106 participants, 16%) were identified as having probable alcohol abuse.

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a second-order factor structures that included two higher-level constructs corresponding to endorsed and anticipated stigma and five first-order factors corresponding to the five proposed scales, and (d) a second-order factor structure that included a single overriding secondorder stigma factor and five first-order factors corresponding to the five proposed scales. We conducted analyses using MPlus Version 3.11 (Muthén & Muthén, 2004) and applied maximum likelihood estimation. The model that corresponded to the five proposed scales provided better fit to the data than any of the alternative model structures that were tested, as indicated in the results presented in Table 4. Although the chi square statistics for all models were significant (p ⬍ .05), this is common in larger samples and indices based on the noncentral chi square (i.e., RMSEA and CFI) are considered more relevant to interpreting fit under these circumstances (Browne & Cudeck, 1993). The RMSEA for the five-factor model demonstrated good fit (Browne & Cudeck, 1993; Hu & Bentler, 1998; Steiger, 1990), and the Comparative Fit Index (CFI; Bentler, 1990) approached the recommended value of .90 (Byrne, 1994). Likewise, the Standardized Root Mean Square Residual (SRMR) was well below the minimum recommended values of .10 (Hu & Bentler, 1998) for the five-factor model. In addition, all items proposed to load on each of the five factors had critical ratios that exceeded 2.00 and all standardized factor loadings for each of the five factors exceeded .40 (average of .64 for Beliefs about Treatment, .66 for Beliefs about Treatment-Seeking, and .66 for Beliefs about Mental Illness, .76 for Concern about Stigma from Loved Ones, and .79 for Concerns about Stigma in the Workplace). In contrast, fit indices for both the two-factor and one-factor models were indicative of poor fit and chi square difference tests demonstrated superior fit for the five-factor model relative to either the two-factor or one-factor models. Fit was also weaker for the two second-order factor structures that were tested. It is noteworthy, however, that the second-order factor structure that specified two higher-level factors corresponding to endorsed and anticipated stigma demonstrated only slightly worse fit than the five-factor model, providing support for the broader distinction that has been drawn between endorsed and anticipated stigma. Further details regarding these factor solutions are available from the first author.

Results. As indicated in Table 2, none of the correlations among either endorsed or anticipated stigma scales exceeded .70, suggesting that each scale addresses unique content (Kline, 2005). The highest correlation was observed between the two anticipated stigma scales, but these scales still shared less than half of their variance with one another (R ⫽ .64; R-squared ⫽ .41). In support of the convergent and discriminant validity of endorsed and anticipated stigma scales relative to other scales in this inventory (Campbell & Fiske, 1959), the average correlations observed among the three endorsed scales (.54) and the correlation between the two anticipated scales (.64) both exceeded the average correlations observed between endorsed and anticipated stigma scales (.29). Given that the EASI assesses beliefs that may portray individuals in an unfavorable light (e.g., “I don’t feel comfortable around people with mental health problems”), it is possible that this set of scales may be affected by a general tendency to respond in a socially desirable manner. Thus, we also examined the association between these scales and a measure of socially desirable response style. As indicated in Table 2, associations between these scales were in the modest range, suggesting that responses on these scales are, at least to a small extent, negatively related to a general tendency to respond in a more socially desirable manner. Prior research indicates that individuals with mental health problems endorse more concerns about stigma. Thus, evidence for discriminative validity would be provided to the extent that individuals with probable mental health problems report more stigma on the EASI scales than individuals who do not meet criteria for mental health problems. For the purpose of this analysis, individuals who met criteria for probable PTSD, depression, or substance abuse (n ⫽ 139 for PTSD, n ⫽ 263 for depression, and n ⫽ 106 for substance abuse) were compared with individuals who did not meet criteria for these mental health conditions. As indicated in Table 3, mean differences were observed on most EASI scales for those with and without these probable mental health conditions, suggesting that individuals with mental health problems endorsed more stigma than those who did not report symptoms consistent with PTSD, depression, or alcohol abuse.

Part 4: Factor Structure Part 4 was an examination of the factor structure of the EASI. Confirmatory factor analyses were conducted to examine the proposed five-factor structure underlying the five scales of the EASI, as it compares with other plausible factor structures. Specifically, this model was compared with: (a) a two-factor model that specified two separate endorsed and anticipated stigma factors, (b) a one-factor model that specified one large factor subsuming all stigma scales, (c)

Summary and Discussion The goal of this study was to create a theoretically grounded and psychometrically strong measure of stigma-related mental health beliefs that could be used with military and veteran populations. Evidence for the content validity, internal consistency reliability, convergent and discriminant validity, discriminative validity, and factor

Table 2 Correlations Among EASI Scales Variable 1. 2. 3. 4. 5. 6.

Beliefs about mental illness Beliefs about mental health treatment Beliefs about treatment seeking Concerns about stigma from loved ones Concerns about stigma in the workplace Social desirability

Note. ns ranged from 646 – 681. ⴱ p ⬍ .05.

1

2

3

4

5

6



.55ⴱ —

.47ⴱ .61ⴱ —

.51ⴱ .49ⴱ .48ⴱ —

.36ⴱ .37ⴱ .38ⴱ .64ⴱ —

⫺.13ⴱ ⫺.25ⴱ ⫺.24ⴱ ⫺.31ⴱ ⫺.25ⴱ —

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Table 3 Mean Differences on EASI Scales for Individuals With and Without Mental Health Problems Above threshold Study Variables Probable PTSD Beliefs about mental illness Beliefs about mental health treatment Beliefs about treatment seeking Concerns about stigma from loved ones Concerns about stigma in workplace Probable depression Beliefs about mental illness Beliefs about mental health treatment Beliefs about treatment seeking Concerns about stigma from loved ones Concerns about stigma in workplace Probable alcohol abuse Beliefs about mental illness Beliefs about mental health treatment Beliefs about treatment seeking Concerns about stigma from loved ones Concerns about stigma in workplace ⴱ

Below threshold

Mean

SD

n

Mean

SD

n

df

t

r

17.46 21.60 22.51 22.23 27.20

5.63 6.36 7.42 8.12 7.66

136 135 135 133 138

18.18 18.74 20.83 17.42 22.75

5.63 5.04 6.66 7.08 7.28

513 515 519 511 511

647 648 652 642 647

1.32 ⫺5.54ⴱ ⫺2.55ⴱ ⫺6.78ⴱ ⫺6.30ⴱ

.05 .21 .10 .26 .24

18.40 20.48 22.38 20.93 26.09

5.76 5.83 7.31 8.08 7.72

253 252 253 250 253

17.89 18.67 20.33 16.93 22.22

5.54 5.03 6.48 6.79 7.04

403 404 407 401 404

654 654 658 649 655

⫺1.11 ⫺4.21ⴱ ⫺3.76ⴱ ⫺6.78ⴱ ⫺6.60ⴱ

.04 .16 .15 .26 .25

17.75 20.13 22.65 19.89 25.39

5.63 5.63 6.98 8.05 7.43

103 106 104 102 105

18.14 19.24 20.87 18.26 23.41

5.64 5.41 6.81 7.42 7.54

553 548 556 547 551

654 652 658 647 654

.64 ⫺1.55 ⫺2.45ⴱ ⫺2.01ⴱ ⫺2.48ⴱ

.03 .06 .10 .08 .10

p ⬍ .05.

struct that has received less attention in the military and veteran literature. Although initial psychometric support for of the EASI is encouraging, additional research is needed to further explore its psychometric properties. For example, evidence is needed for the test–retest reliability of this suite of scales, and it will be important to validate the psychometric characteristics of the EASI in other military and veteran samples, including current servicemembers and other veteran cohorts (e.g., Vietnam veterans). In addition, though this measure was specifically developed for use in military and veteran populations, future research should examine its generalizability to other groups with high base-rate mental health problems. Future studies should also explore how this measure relates to other measures that address related aspects of mental health stigma, such as the Perceived Stigma and Barriers to Care for Psychological Problems measure (Britt, 2000). It will be especially important to evaluate how the endorsed stigma scales assessed in the EASI relate to measures of other components of the self-stigmatization process. For example, an important research question pertains to the impact of endorsed stigma on the self-esteem of individuals who experience mental health problems, as internalized stigma is likely to be a key mechanism through which negative beliefs about mental illness and mental health treatment have their impact on

structure of the EASI was provided. The full inventory takes less than 10 minutes to complete. As such, it offers an efficient tool for assessing dimensions of both endorsed and anticipated mental health stigma that are likely to have implications for mental health treatment. Findings based on the EASI can be applied to inform public health interventions targeted at reducing mental health stigma among military and veteran populations. Specifically, this scale can be used to pinpoint specific components of stigma that require attention in public health campaigns. For example, if negative beliefs about treatment seeking are found to be a key barrier to care, this would suggest the need for interventions targeted at encouraging and normalizing helpseeking. Alternatively, the findings that negative beliefs about mental illness or mental health treatment are particularly common would underscore the importance of efforts aimed at correcting misperceptions about people with mental illness and educating military personnel and veterans about the benefits of mental health treatment. Scales from the EASI may also be applied to identify subpopulations that would benefit most from public health interventions. For example, if men were identified as more likely to hold negative beliefs about mental health treatment than women, it would suggest a greater need for interventions targeted to male rather than female veterans. Moreover, the EASI assesses anticipated stigma from loved ones, a conTable 4 Goodness-of-Fit Indices for Five-, Two-, and One-Factor Models

Model fit Model 1. 2. 3. 4. 5.

Five-factor model Two-factor first-order model One-factor first-order model Two-factor second-order model One-factor second-order model

Note. N ⫽ 698. ⴱ p ⬍ .05.



2 ⴱ

2455.32 5289.65ⴱ 7517.34ⴱ 2484.10ⴱ 2606.04ⴱ

Comparison

df

RMSEA

CFI

SRMR

Models

2 ␹diff

dfdiff

730 739 740 734 735

.06 .09 .12 .06 .06

.89 .71 .57 .89 .88

.05 .08 .10 .05 .06

1 vs. 2 1 vs. 3 1 vs. 4 1 vs. 5

2834.33ⴱ 5062.02ⴱ 28.68ⴱ 150.72ⴱ

9 10 4 5

ENDORSED AND ANTICIPATED STIGMA INVENTORY

treatment seeking. It is also important to recognize that responses to EASI scales are modestly associated with concerns about social desirability. Thus, researchers who use this inventory of scales in future studies may wish to consider controlling for social desirability as appropriate. Finally, it is important to recognize that not all mental health beliefs addressed in the EASI necessarily represent beliefs that are based on biased or inaccurate appraisals. For example, the concern that there may be negative career consequences if supervisors or coworkers know about mental health problems is often a valid concern for military personnel, given that commanding officers may use medical records to inform decisions about whether a servicemember is fit to perform specific job responsibilities (Porter & Johnson, 1994; Rosen & Corcoran, 1978). Likewise, some personal beliefs about mental illness and mental health treatment may be valid. For example, concerns about the negative side effects of medication for mental health problems may be quite well-founded in some cases. In conclusion, the EASI is a new inventory that assesses mental health beliefs that may be particularly salient for military and veteran populations. It is our hope that the availability of these scales will spur further research on the role of mental health stigma in servicemembers’ and veterans’ willingness to seek mental health treatment, and inform interventions aimed at addressing aspects of mental health stigma that serve as barriers to care.

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113

Appendix Items From the Endorsed and Anticipated Stigma Inventory (EASI) 4.

Most mental health problems can be dealt with without seeking professional help.

5.

Seeing a mental health provider would make me feel weak.

6.

3. Most people with mental health problems are just faking their symptoms.

I would think less of myself if I were to seek mental health treatment.

7.

4. I don’t feel comfortable around people with mental health problems.

If I were to seek mental health treatment, I would feel stupid for not being able to fix the problem on my own.

8.

I wouldn’t want to share personal information with a mental health provider.

Beliefs About Mental Illness 1.

People with mental health problems cannot be counted on.

2. People with mental health problems often use their health problems as an excuse.

5. It would be difficult to have a normal relationship with someone with mental health problems. 6. Most people with mental health problems are violent or dangerous. 7. People with mental health problems require too much attention. 8.

People with mental health problems can’t take care of themselves.

Beliefs About Mental Health Treatment

Concerns About Stigma From Loved Ones If I had a mental health problem and friends and family knew about it, they would . . . 1.

. . . think less of me.

2.

. . . see me as weak.

3.

. . . feel uncomfortable around me.

4.

. . . not want to be around me.

1.

Medications for mental health problems are ineffective.

5.

. . . think I was faking.

2.

Mental health treatment just makes things worse.

6.

. . . Be afraid that I might be violent or dangerous.

3.

Mental health providers don’t really care about their patients.

7.

. . . think that I could not be trusted.

4.

Mental health treatment generally does not work.

8.

. . . avoid talking to me.

5.

Therapy/counseling does not really help for mental health problems.

6.

People who seek mental health treatment are often required to undergo treatments they don’t want.

Concerns About Stigma in the Workplace If I had a mental health problem and people at work knew about it . . .

7.

8.

Medications for mental health problems have too many negative side effects. Mental health providers often make inaccurate assumptions about patients based on their group membership (e.g., race, sex, etc.).

Beliefs About Treatment Seeking 1.

A problem would have to be really bad for me to be willing to seek mental health care.

2.

I would feel uncomfortable talking about my problems with a mental health provider.

3.

If I had a mental health problem, I would prefer to deal with it myself rather than to seek treatment.

1.

My coworkers would think I am not capable of doing my job.

2.

People at work would not want to be around me.

3.

My career/job options would be limited.

4.

Coworkers would feel uncomfortable around me.

5.

A Supervisor might give me less desirable work.

6.

A Supervisor might treat me unfairly.

7.

People at work would think I was faking.

8.

Co-workers would avoid talking to me. Received August 6, 2012 Revision received January 28, 2013 Accepted January 28, 2013 䡲

Endorsed and Anticipated Stigma Inventory (EASI): a tool for assessing beliefs about mental illness and mental health treatment among military personnel and veterans.

Many military personnel and veterans who would benefit from mental health treatment do not seek care, underscoring the need to identify factors that i...
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