Public stigma in intellectual disability: do direct versus indirect questions make a difference?

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Journal of Intellectual Disability Research

doi: 10.1111/jir.12207

958 VOLUME

59 PART 10 pp 958–969 OCTOBER 2015

Public stigma in intellectual disability: do direct versus indirect questions make a difference? S. Werner Paul Baerwald School of Social Work and Social Welfare, Hebrew University of Jerusalem, Jerusalem, Israel

Abstract Background Stigma may negatively impact individuals with intellectual disabilities (ID). However, most studies in the field have been based on the use of direct measurement methods for assessing stigma. This study examined public stigma towards individuals with ID within a representative sample of the Israeli public by comparing direct versus indirect questioning. Methods Vignette methodology was utilised with two questionnaire versions. In the direct questionnaire (n = 306), the participants were asked how they would think, feel and behave if a man with ID asked them a question in a public place. In the indirect questionnaire (n = 301), the participants were asked to report how a hypothetical ‘other man’ would think, feel and behave in the same situation. Results Higher levels of stigma were reported among participants that answered the indirect questionnaire version. Furthermore, among those participants that answered the indirect questionnaire version, subjective knowledge of ID was a less important correlate of stigma than for those participants that answered the direct questionnaire. Conclusion Several explanations are suggested for the finding that indirect questioning elicits more negative stigmatic attitudes. Among others, indirect questioning may be a more appropriate methodology for eliciting immediate beliefs. Furthermore, the

Correspondence: Dr. Shirli Werner, Paul Baerwald School of Social Work and Social Welfare, Hebrew University of Jerusalem, Mount Scopus, Jerusalem, 91905, Israel (e-mail: [email protected]).

results call for implementing a comprehensive, multilevel programme to change stigma. Keywords attitudes, automatic stereotyping, direct and indirect questioning, intellectual disability, stigma

Introduction Stigma results in widespread social disapproval and devaluation of individuals who possess an attribute that others consider to be negative, unfavourable or unacceptable (Goffman 1963; Dovidio et al. 2000). Public stigma refers to the reactions of individuals from the general public, including their cognitive, affective and behavioural reactions towards the stigmatised individual (Pryor & Reeder 2011). Stigma towards individuals with intellectual disabilities (ID) plays an integral role in their lives, because this group is among the most stigmatised groups in the society (Miller et al. 2009). People with ID are frequently marginalised and discriminated against in their daily, social and civic life. They frequently encounter substantial disparities in health, housing and employment, and lack of inclusion in community life, and they experience increased social distance (Kersh 2011; Ditchman et al. 2013; Werner & Roth 2014). In addition, studies have shown that people with ID have been subjected to frequent teasing, staring, name-calling, ridicule and exclusion (Cooney et al. 2006; Siperstein et al. 2007). Moreover, awareness of stigma subjects individuals with ID to psychological distress, decreased self-

© 2015 MENCAP and International Association of the Scientific Study of Intellectual and Developmental Disabilities and John Wiley & Sons Ltd


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59 PART 10 OCTOBER 2015

959 S. Werner • Stigma in intellectual disability

esteem and increased vulnerability to mental health problems (Jahoda et al. 2010; Ditchman et al. 2013). Thus, it is highly important to determine the level of stigma inherent in the society. Until recently most empirical research in the area of ID stigma was limited and atheoretical (Scior 2011; Werner et al. 2012). Recently, researchers have proposed a theoretical framework for ID stigma based on more widely known mental illness stigma theories. This theoretical conceptualization views stigma as a process consisting of stereotypes (i.e. knowledge structures about a larger group of people), prejudice (i.e. the generated negative emotional reaction) and discrimination (i.e. behaviour towards the stigmatised individual). Although based on the theoretical framework of mental illness stigma, ID stigma was found to have some unique aspects. Specifically, stereotypes were found to include positive cognitions of acceptance and negative cognitions of low ability and dangerousness. Prejudice consisted of both negative and calm affect. Finally, behavioural aspects included discrimination (withdrawal behaviours and social distance), as well as positive behaviours of helping (Werner, in press). Earlier studies have shown that people with ID are often perceived as aggressive (Slevin & Sines 1996), lacking the potential to change (Jahoda & Markova 2004), childish (Caruso & Hodapp 1988), possessing limited abilities (Siperstein et al. 2003) and dependent on others (Siperstein & Bak 1980). More recent studies, however, have found that the level of the reported public stigma towards people with ID was actually relatively low. For example, a recent study found low levels of public stigma towards individuals with ID among the Israeli public, manifested by a low ranking on dimensions of dangerousness, negative affect and withdrawal. Higher rankings, but still below the mid-point of the scale, were found for the dimensions of low ability and social distance. Finally, the positive dimensions of acceptance, feeling calm in an interaction and helping were all ranked above the mid-point of their scale (Werner, in press). In agreement with these findings, a study conducted among a representative sample of Quebec citizens found positive public attitudes regarding the cognitive, affective and behavioural dimensions of attitudes (Morin et al. 2013). In Ontario, participants tended to indicate a very low social distance regarding their interactions with individuals with ID (Ouellette-

Kuntz et al. 2010). Finally, a study conducted in the UK found social distance to be around the mid-point of the scale (Scior et al. 2013). One of the main reasons attributed to these low levels of reported stigma is the questionable validity inherent within the instruments being utilised in these studies (Akrami et al. 2006; Ouellette-Kuntz et al. 2010), which were all based on direct questioning. In an effort to expand this line of research, the current study compares the use of direct versus indirect questioning methods for assessing public stigma in the area of ID. Direct methods are those in which the respondents are either informed that their attitudes are being measured or are aware of it by the nature of the measurement technique (Antonak & Livneh 1995). Direct methods are subject to a number of concerns in terms of validity, the biggest being social desirability, where the basic human inclination to present oneself in the best possible light can distort the information provided (Fisher 1993; Jo 2000). Indirect questioning may overcome the effects of social desirability, by asking respondents to report on what other people think about sensitive issues (Snijders & Matzat 2007). The underlying notion is that the respondents actually project their own attitudes using the façade of ‘another person’ (Fisher 1993). Although indirect methods have gained considerable popularity in general attitude research, these methods have rarely been employed in research examining public stigma towards individuals with ID. A recent systematic review of measures identified 17 instruments that measured public stigma, but only three of them included some type of indirect or projective measure, and all had many inherent shortcomings such as not measuring all three stigma dimensions (stereotypes, prejudice and discrimination) (Werner et al. 2012). Another review found only four studies that specifically utilise an implicit-association test to examine attitudes towards individuals with ID (Wilson & Scior 2014). Thus, more research is needed in order to better understand how the different types of questioning affect reports of public stigma and its correlates. The first objective of this study was to assess whether direct versus indirect questions make a difference in the reporting of stigma towards individuals with ID within a nationally representative



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sample of the general public in Israel. The second objective was to determine whether there are differences in the correlates of public stigma towards individuals with ID when examined via direct versus indirect questioning. Two central correlates were examined: familiarity and knowledge, which, in most studies about stigma and ID, have been found to be negatively associated with stigmatic beliefs (Werner, in press; Scior & Furnham 2011).

Methods Participants The participants included a national representative sample of the adult (18+) non-institutionalised population in Israel. Participants were sampled using a probabilistic sampling of statistical areas defined by social demographic characteristics to ensure proper representation of different population groups. Of the 1421 phone calls that were made using random digit dialling, 48 phone numbers were disconnected and 17 were either commercial or fax numbers, and with 26 phone calls, we encountered communication problems (e.g. a language problem, a hearing problem or the inability to answer a phone survey). Of the remaining 1330 numbers, 656 people refused to participate, 43 were not successfully contacted after four trials and 24 completed the survey only partially. Thus, overall, 607 interviews were completed, representing a response rate of 45.6%. Of these participants, 506 (83.4%) were Jewish and 101 (16.6%) were of other religion, mainly Muslims. The sample was fairly evenly distributed between men (48.8%) and women (51.2%). The mean age of the participants was 48.9 years [standard deviation (SD) = 16.7; range 18–87]. Furthermore, 10.0% of the participants had below high-school education, 38.9% had completed high school and 51.0% had education beyond high school. Of these participants, 66.7% reported that they had previous familiarity with an individual with ID. Further, 34.5%, 32.5% and 33.2% reported low, medium and high levels of subjective knowledge in ID, respectively.

Instruments Two questionnaire versions were utilised using two case vignettes. The direct version (N = 306) was adapted from a previously developed and validated

questionnaire. In the current study, participants were read a vignette (previously examined for face validity by experts within the ID field; Werner, in press) asking them to imagine a scenario in which they were out in a public place when a man aged 30 years with ID turned to them with a question (Appendix 1). A brief description of the individual was provided, in line with the criteria for ID: The man’s intelligence is lower than average. He has difficulty understanding complex matters. He does not know how to read or write. He lives in a sheltered community setting and works within the warehouse of a clothing company. The man can take care of himself in some fields of life, such as getting ready for work and showering independently but needs help in making food and managing financial affairs. Although in real-life encounters, most individuals would not be aware of some of the aforementioned information, it was important for us to make this information available in the vignette in order to make sure that participants had a clear picture of the individual. Next, the participants were asked to answer 34 items that were divided into three sections measuring their cognitive, affective and behavioural reactions. Each section was preceded by the following instruction: ‘people have a variety of emotions (thoughts/ behaviors) when they meet a man with ID like the man I described to you. Regarding each of the following emotions (thoughts/ behaviors), please indicate to what extent might you feel (think/ behave) this emotion (thought/ behavior) when the man turns to you within a public place’. In the indirect version (N = 301), a man named Joseph was described as being in the same situation described earlier, that is, meeting a man with ID in a public place. Participants were asked to answer the same 34 items. The instructions were adjusted to read ‘to what extent might Joseph feel (think/ behave)… when the man turns to him within a public place’. For all items, the participants’ agreement was rated on a Likert-type scale ranging from 1 (little or none) to 5 (very much). Stereotypes (cognitive dimension) were assessed by asking the participants to rate the likelihood that they would think of all seven items. This scale consisted of three factors: acceptance included two items (e.g. You will think he looks friendly); low ability included three items (e.g. You will think the man has low ability); and ‘dangerousness’, included two items (e.g.



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You will worry that the man will be aggressive towards you). Internal reliabilities of the three factors were moderate (acceptance, α = 0.66; low ability, α = 0.73; dangerousness, α = 0.74). Prejudice (affective dimension) was examined via 16 items that were divided into two factors: negative affect, included 13 emotions (e.g. disgust) with good internal reliability (α = 0.90) and calm affect, included three items (e.g. serenity) with moderate internal reliability (α = 0.69). One item (‘indifference’) from the original version was dropped because it had the lowest loading and it was not perceived to be a clear negative affect. Discrimination (behavioural dimension) included 11 items that measured three factors. Withdrawal behaviour was measured by five items (e.g. pretending not to hear). Social distance included four items (e.g. being served by the man at a coffee shop) that were recorded in such a way that the higher scores indicated greater social distance. Finally, helping behaviour included two items (e.g. asking whether he needs something else). The Cronbach alpha coefficients were α = 0.91 for withdrawal, α = 0.83 for social distance and α = 0.75 for helping behaviour. The item ‘will answer his question’ was dropped as in the adaptation of the vignette, the researchers thought this item may cause confusion. Familiarity was examined using one yes/no item ‘Are you personally familiar with a person with ID?’ Subjective knowledge was examined using one item ‘To what degree do you feel you have knowledge about ID’, rated on a five-point scale from 1 = to a very low degree to 5 = very much. The Hebrew version of the questionnaire was translated to Arabic and Russian by highly skilled professional translators working at the Cohen Institute for Public Opinion Research. These versions were back-translated to Hebrew to make sure that the original meaning of the items was retained.

Procedures The study questionnaire was piloted in telephone interviews with a sample of 15 participants. Main study data were collected in November 2013 via a telephone interview conducted in Hebrew, Russian or Arabic. Participants answered one of the two randomly distributed questionnaire versions. Each telephone interview lasted approximately 15 min.

Ethical considerations The study’s protocol was approved by the Ethics Committee of the Paul Baerwald School of Social Work and Social Welfare within the Hebrew University.

Data analyses First, differences regarding public stigma individual scale items according to the two questionnaire versions were examined using Mann–Whitney U tests (ordinal scale) and independent t-tests for ascertaining differences in the index component score (continuous variables). Second, the association between familiarity and stigma was examined via ttests, and the association between subjective knowledge and stigma was examined via Pearson correlations.

Results Participants’ background according to the questionnaire version Table 1 presents the participants’ background characteristics according to the two questionnaire versions. As expected, no statistically significant differences were found regarding the ethnic background, gender, education, income, familiarity with ID, age and subjective knowledge between the groups.

Differences in public stigma according to the questionnaire version Table 2 presents the differences in public stigma between direct versus indirect questionnaire versions. Overall, it was observed that higher levels of stigma were reported by participants who answered the indirect questionnaire. More specifically, among the three stereotype factors, statistically significant differences were found regarding acceptance and low ability: participants who received the indirect version of the questionnaire reported more negative stereotypes than did those who received the direct questionnaire. Indeed, only on two individual items were no statistically significant differences found when comparing the questionnaire versions. These two items were related to the perception of the dangerousness of an individual with ID. In terms of prejudice, statistically significant differences were found for all items when comparing



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Table 1 Participants’ background according to the questionnaire version (N = 607)

Ethnic background Jewish Non-Jewish Gender Male Female Education Below high school High school Above high school Income Low Medium High Familiarity with ID Not familiar Familiar Age Subjective knowledge

Direct version (N = 306)

Indirect version (N = 301)

N (%)

N (%)

253 (82.7) 53 (17.3)

253 (84.1) 48 (15.9)

Difference 2 statistics ( χ )

2

χ = 0.21, P > 0.05 2

χ = 0.02, P > 0.05 150 (49.0) 156 (51.0)

146 (48.5) 155 (51.5)

32 (10.5) 115 (37.6) 159 (52.0)

29 (9.6) 121 (40.2) 151 (50.2)

127 (48.7) 60 (23.0) 74 (28.4)

120 (46.9) 60 (23.4) 76 (29.7)

92 (30.1) 214 (69.9) M = 48.5 (SD = 16.0) M = 3.0 (SD = 1.17)

110 (36.5) 191 (63.5) M = 49.3 (17.4) M = 2.9 (SD = 1.23)

2

χ = 0.47, P > 0.05

2

χ = 0.19, P > 0.05

2

χ = 2.87, P > 0.05 t = 0.52, P > 0.05 t = 0.72, P > 0.05

SD, standard deviation; M, mean.

the two questionnaire versions as well as regarding the overall indices. Higher scores were reported on all negative affect items by participants who answered the indirect questionnaire, whereas higher scores on all calm affect items were reported by those who answered the direct questionnaire version. Similarly, regarding discrimination, statistically significant differences were found when comparing the questionnaire versions for all individual items as well as each of the three overall discrimination factors. Specifically, more withdrawal behaviour, more social distance and less helping behaviours were reported by participants who answered the indirect questionnaire versus the direct questionnaire.

Familiarity and knowledge as correlates of public stigma in the direct and indirect questionnaire versions

calm affect [t(304) = 4.13, P < 0.001], more helping behaviours [t(304) = 2.85, P < 0.001] and lower social distance [t(304) = 4.27, P < 0.001] than did participants not familiar with people having ID. Similar results, although with a lower degree of significance, were found among those participants who answered the indirect questionnaire version. Specifically, among participants that answered the indirect questionnaire version, those familiar with persons with ID reported a greater calm affect [t(299) = 2.37, P < 0.05], more helping behaviours [t(299) = 2.49, P < 0.05] and less social distance [t(299) = 2.30, P < 0.05]. However, no statistically significant differences were found between the two groups in terms of acceptance. Furthermore, individuals who answered the indirect questionnaire version and were familiar with people with ID also reported more negative affect than those who were not familiar [t (299) = 1.97, P = 0.05].

Familiarity As shown in Table 3, among those participants who answered the direct questionnaire version, those familiar with persons with ID reported greater acceptance [t(304) = 2.51, P < 0.05], a greater degree of

Subjective knowledge As shown in Table 4, among those participants who answered the direct questionnaire version, subjective



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Table 2 Differences in public stigma between the direct and indirect questionnaire versions (N = 607)

Stereotypes (cognitive)† Acceptance Will think he looks friendly Will think he seems like an interesting person Low ability Will think he has low ability. Will think he looks childish Will think he is slow Dangerousness Will worry that he is dangerous to others Will worry that he can be aggressive towards you Prejudice (affective)‡ Negative affect Shame Fear Guilt Shyness Upset Stress Nervousness Depression Disgust Tension Helplessness Embarrassed Uneasiness Calm affect Relaxation Serenity Calmness Discrimination (behavioural)§ Withdrawal behaviour Stay away from him Pretend not to hear Dwell on reading the newspaper or talking on a cell phone Continue what you were doing Find an excuse to leave Social distance Be his neighbour Be his friend Be served by him at a coffee shop Work with him within the same room at work Helping behaviour Ask whether he needs something else Initiate the continuation of the conversation

Mann–Whitney U/t-value

Direct (N = 306)

Indirect (N = 301)

Mean (SD)

Mean (SD)

3.09 (1.01) 3.34 (1.03) 2.97 (1.20) 2.89 (0.96) 3.08 (1.18) 2.61 (1.21) 3.01 (1.19) 1.92 (1.00) 1.81 (1.02) 2.01 (1.14)

2.88 (1.03) 3.16 (1.09) 2.68 (1.20) 3.17 (0.96) 3.29 (1.13) 2.90 (1.24) 3.28 (1.05) 2.04 (0.96) 1.94 (1.10) 2.13 (1.09)

2.50* 33412.5* 33122.5** 3.53*** 46130.0* 43705.0** 45375.0* 1.48 44138.5 44905.0

1.45 (0.51) 1.30 (0.78) 1.43 (0.83) 1.25 (0.64) 1.48 (0.94) 1.31 (0.71) 1.52 (0.91) 1.46 (0.88) 1.40 (0.79) 1.26 (0.65) 1.51 (0.90) 1.75 (1.07) 1.51 (0.87) 1.68 (0.99) 3.49 (1.13) 3.71 (1.40) 3.46 (1.31) 3.38 (1.43)

1.89 (0.77) 1.81 (1.14) 1.88 (1.17) 1.59 (1.00) 1.85 (1.19) 1.80 (1.12) 2.01 (1.20) 1.74 (1.00) 1.70 (1.04) 1.81 (1.11) 2.01 (1.15) 2.08 (1.22) 2.03 (1.11) 2.19 (1.16) 2.93 (1.03) 3.16 (1.35) 2.81 (1.29) 2.82 (1.31)

8.29*** 56306.0*** 53572.0*** 51425.0*** 51678.0*** 55173.5*** 55277.0*** 51944.5*** 51371.0*** 56195.5*** 56274.0*** 51106.5*** 56756.5*** 56556.5*** 6.33*** 32766.5*** 29435.5*** 31353.0***

1.47 (0.69) 1.63 (0.94) 1.37 (0.80) 1.34 (0.71) 1.47 (0.89) 1.52 (0.90) 2.60 (1.04) 3.45 (1.21) 2.75 (1.34) 3.85 (1.31) 3.55 (1.28) 3.17 (1.13) 3.62 (1.24) 2.76 (1.33)

2.10 (1.04) 2.06 (1.17) 1.93 (1.11) 2.05 (1.20) 2.11 (1.22) 2.30 (1.27) 2.95 (1.03) 2.99 (1.27) 2.49 (1.25) 3.41 (1.28) 3.23 (1.28) 2.86 (1.12) 3.12 (1.20) 2.57 (1.23)

8.76*** 54049.0*** 58449.5*** 59870.5*** 58517.0*** 60805.5*** 4.23*** 34016.5*** 37390.5* 34643.5*** 37339.0*** 3.39*** 34063.0*** 38983.0***

*P < 0.05, **P < 0.01, ***P < 0.001. † All items in this section were reworded in the indirect version as ‘He (Joseph) will think that…’. ‡ All items in this section were reworded in the indirect version as ‘Joseph will feel…’. § All items in this section were reworded in the indirect version as ‘He (Joseph) will ....’. SD, standard deviation.



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Table 3 Familiarity and public stigma towards people with an intellectual disability by use of direct and indirect questioning

Direct

Stereotypes Acceptance Low ability Dangerousness Prejudice Negative affect Calm affect Discrimination Withdrawal Helping Social distance

Indirect

Not familiar (N = 92) Mean (SD)

Familiar (N = 214) Mean (SD)

Not familiar (N = 110) Mean (SD)

Familiar (N = 191) Mean (SD)

2.87 (0.97) 2.86 (0.91) 2.05 (1.01)

3.18 (1.01)* 2.91 (0.99) 1.86 (0.99)

2.86 (1.00) 3.04 (1.01) 2.13 (0.97)

2.90 (1.05) 3.24 (0.93) 1.99 (0.95)

1.52 (0.51) 3.09 (1.18)

1.42 (0.50) 3.66 (1.07)***

2.01 (0.78) 2.75 (1.04)

1.83 (0.75)* 3.04 (1.01)*

1.54 (0.72) 2.89 (1.08) 2.97 (1.05)

1.45 (0.67) 3.29 (1.13)** 2.43 (0.99)***

2.20 (1.05) 2.65 (1.08) 3.13 (1.03)

2.04 (1.03) 2.98 (1.13)* 2.85 (1.01)*

*P < 0.05, **P < 0.01, ***P < 0.001. SD, standard deviation.

Table 4 Correlations between public stigma and subjective knowledge by use of direct and indirect questioning

Subjective knowledge (Pearson R) Direct (n = 306) Stereotypes Acceptance Low ability Dangerousness Prejudice Negative affect Calm affect Discrimination Withdrawal Helping Social distance

Indirect (n = 301)

0.19*** 0.08 0.11

0.06 0.05 0.05

0.08 0.14*

0.03 0.07

0.09 0.20*** 0.22***

0.03 0.15* 0.05

*P < 0.05, ***P < 0.001.

knowledge was positively correlated with acceptance stereotypes, the calm affect and helping behaviours, but it was negatively correlated with social distance. Among those participants who answered the indirect questionnaire version, the only statistically significant correlation found was a positive association between subjective knowledge and helping behaviours.

Discussion This study, to the best of our knowledge, was the first to examine public stigma towards people with ID among a representative sample of the Israeli public by comparing direct versus indirect questioning. First, our findings provide important insight related to the varying levels of public stigma, as reported via the two methods. Second, they indicate that the relationship between public stigma and subjective knowledge differs when indirect questioning is utilised.

Levels of public stigma towards people with intellectual disability using two methods of questioning In both questionnaire versions, although the vignette described the individual as having lower intelligence and difficulties in several life domains, participants rated the factor of ‘low ability’ only a bit above the mid-point of the scale. One explanation may be that although the description suggested that the individual had some difficulties, the words ‘low ability’ were not utilised. This shows that difficulties were not automatically translated in the participants’ mind to mean low ability. In line with this, the specific stereotypes of being childish and being slow were not specifically described in the vignette. A final



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explanation may be social desirability leading participants to report lower values. Nevertheless, the importance of the current results is in showing that the lay public in Israel reported higher levels of stigma towards people with ID when indirect, rather than direct, questioning was employed. This was manifested by the higher levels of negative stereotypes (lower levels of acceptance and a greater perception of low ability), higher levels of prejudice (more negative affect and less calm affect) and higher levels of discrimination (more reports of withdrawal and social distance and fewer reports of helping behaviours). These findings are in line with studies from other fields (Rüsch et al. 2011) as well as studies from the ID field (Wilson & Scior 2014), which have shown more frequent negative reactions when implicit measures are utilised. Several factors may account for these findings. First, direct questioning may have initiated control processes in a conscious effort to conform to norms of being kind and positive towards individuals with ID. In contrast, indirect questioning may have reduced social desirability and allowed the participants to express more freely socially undesirable attitudes (Fisher 1993). These findings may support the assumptions of ‘dual-process’ models of attitude formation in that the indirect questioning may have had a greater ability to elicit more immediate reactions held by individuals (Pryor et al. 2004). In support of this hypothesis, theories of stereotype activation versus stereotype application lead us to understand that in answering direct questions, individuals have a greater motivation to control their prejudice. Thus, these individuals may report lower levels of stereotype application than those answering an indirect questionnaire who are less motivated to control their prejudice (Kunda & Spencer 2003). These findings may suggest that levels of stigma gathered via indirect questioning provide a more realistic description of the level of public stigma towards individuals with ID within the Israeli society. An alternative explanation for the higher level of stigma towards individuals with ID among participants who answered the indirect questionnaire is the possibility that instead of projecting their own attitudes, these participants reported on how they feel that others, among the Israeli public, perceive

individuals with ID. Although this could be considered an inherent limitation to the indirectquestioning methodology, the findings are nevertheless important because they point to the way in which people with ID may be perceived by the Israeli society at large (Link & Cullen 1983). This is important as stigmatic attitudes at the individual level originate and develop from learning experiences inside ones’ culture (Fazio & Olson 2003). Another important finding of the current study is that among the three stigma dimensions, questioning methodology resulted in more noteworthy differences in the prejudice (affective) and the discrimination (behavioural) dimensions. This is important because it is known that discriminating behaviours negatively impact individuals with ID (Ditchman et al. 2013) and that prejudiced reactions are at the core of this discrimination (Corrigan et al. 2003). One possibility for these findings is that immediate reactions, as elicited via indirect questioning, are especially relevant for spontaneous affective reactions (Gawronski & Bodenhausen 2006; Greenwald & Nosek 2009) and less relevant to knowledge structures, as seen in studies regarding automatic stereotyping in other fields (Rüsch et al. 2011). Furthermore, behaviour has been known to be, at least partially, predicted by implicit attitudes (Wilson & Scior 2014). However, this explanation should be approached with caution because in this study, we cannot state with certainty that the stigma reported via the indirect questioning indeed consisted of automatic reactions.

Subjective knowledge and familiarity as correlates of stigma First, the degree of familiarity with ID in the current sample was relatively high, in line with the level found in previous public surveys in Israel (Werner, in press), but higher than levels found in other studies (e.g. Durand-Zaleski et al. 2012). The high rates found in the current study may be related to the way the concept of familiarity was examined in the current study. Participants were asked to answer a binary question, whether they were familiar or not with an individual with ID. This may have allowed for the inclusion of relatively superficial types of familiarity. This is in line with studies showing that most



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individuals have some degree of familiarity with individuals with disabilities (Corrigan et al. 2001). Interestingly, almost no statistically significant associations were found between participants’ subjective knowledge and the various stigma dimensions regarding individuals with ID among participants who were interviewed using the indirect questionnaire. These findings differ from previous research, mainly conducted with direct methods, showing consistently the great importance of knowledge on the levels of stigma (Werner, in press; Hampton & Xiao 2008). Although similar to subjective knowledge, familiarity was a weaker correlate of stigma when indirect questioning was used; nevertheless, it was still associated with four of the stigma dimensions (the negative affect, the calm affect, helping and social distance). This finding is in line with previous studies (Werner, in press; Scior & Furnham 2011) pointing towards the importance of familiarity and contact in forming stigma. It is possible that familiarity with an individual with ID, more so than subjective knowledge, has a strong influence on both reactions elicited via direct questioning and reactions elicited via indirect questioning. Nevertheless, findings of the weaker correlation between stigma and both subjective knowledge and familiarity among those respondents that answered an indirect questionnaire merit further discussion and exploration. This difference can be explained by the fact that in their attitude formation process, those participants who answered an indirect questionnaire relied on their knowledge and familiarity of the ID field to a lesser degree than did those participants who answered a direct questionnaire. As previously described, when answering an indirect questionnaire, the participants may have been less concerned with social desirability, and they tend to be more likely to report their immediate perceptions and invest less effort in activating their knowledge in order to examine the truth base of their perceptions (Gawronski & Bodenhausen 2006). Conversely, participants answering a direct questionnaire clearly know that their own perceptions are being assessed; hence, they rely more strongly on conscious, deliberative and thoughtful reactions and the gathering of accurate knowledge (Reeder & Pryor 2008). In support of this hypothesis, theories of stereotype application have shown that controlling prejudice is

an effortful process. People may be better able to suppress their stereotype application when they have the necessary cognitive resources (Devine 1989; Kunda & Spencer 2003). Thus, when answering a direct questionnaire, people may more frequently call upon their previous knowledge and experiences of familiarity in forming their stereotype perceptions. An alternating explanation to these results relates to the possibility that in answering a projective questionnaire, individuals reported on how they perceive other’s attitudes. In this case, the individuals’ own subjective knowledge is not relevant to other’s attitudes. Nevertheless, as most previous studies in this field have utilised direct questionnaire, this issue should be further examined using additional indirect measuring instruments.

Study limitations Several limitations of this study should be noted. First, each participant answered only one questionnaire version, not allowing for a withinparticipant comparison. Second, although indirect questioning has been shown to be effective, it is also limited by possible validity problems by reporting what ‘typical others’ may think rather than the individuals’ own opinion (Fisher 1993). Thus, we cannot entirely ascertain the frame of reference used by the participants in their answers. Third, the results are limited to the specific vignette, which does not provide information on the variability between different people with ID and was not matched to the gender of the participant. Thus, the results may not reflect the responses that would be given to other individuals with ID. Nevertheless, vignette methodology has been reported as a useful research tool in stigma research (Angermeyer & Matschinger 2005). In addition, the vignette provided much information on the diagnosis and difficulties of the individual with ID. In most real-life encounters with an individual with a disability, the person is only exposed to the appearance and behaviour of the individual, thus arguing that the vignette situation is artificial. Future studies should alter the vignette or manipulate an experimental design, in order to test if the findings hold in real-life encounters. Fourth, this study did not control for participants’ cultural religious background. A previous study has shown that results regarding the role of religion in ID



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stigma within the Israeli society are mixed (Werner, in press). Although a similar mix of both religious backgrounds answered each of the questionnaire versions, future studies should control for cultural religious background. Fifth, this study utilised cross-sectional data; thus, causation cannot be determined. Finally, we did not assess social desirability; thus, it is difficult to determine whether such a factor played a role in the participants’ responses.

Conclusions and implications Methodologically, this study is one of the first to examine stigma towards individuals with ID using indirect techniques, and it was one of the first to examine this issue within the general public. Furthermore, this study adds to the growing field of knowledge showing the importance of assessing stigma in the ID field via projective techniques (Wilson & Scior 2014). The indirect methodology utilised here differs from the more frequently used implicit-association test. First, whereas implicit tests usually ask participants to categorise terms into two opposing attribute categories (e.g. pleasant versus unpleasant), the current methodology examined a wide range of attributes that are coded on a Likert-type scale, allowing for a variety of responses. Second, implicit tests usually focus solely on attitudes and fail to examine stigma multidimensionally. Especially important in the current methodology is the examination of the behavioural dimension (discrimination), which has had the most important impact on the everyday experiences of individuals with ID. Third, although implicit tests involving paper and pencil are available, they are more frequently and more properly conducted in computerised versions. The method used in the current study may be more suitable for studies requiring a paper and pencil design. Finally, this study showed the importance of examining stigma correlates (e.g. knowledge and familiarity), which have been frequently lacking in implicit-association studies of disabilities, and especially the ID field (Wilson & Scior 2014). In terms of practical implications, stigma change interventions must focus on various processes of stigma in order to ensure an

encompassing change in stigma. To be encompassing, stigma change requires a multilevel framework with interventions aimed at changing attitudes at the intrapersonal, interpersonal and structural levels (Cook et al. 2014). Especially important is the need to tackle implicit attitudes because they are most likely to have a negative impact on the everyday experiences of individuals with ID. Stigma change interventions must target the core stereotypes that are inherent within a society regarding people with ID.

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Appendix 1: Vignettes Direct vignette I want to ask you to imagine the following scenario: You are in a public place, for example, a bus station, a coffee shop, or waiting in line for a movie when a 30-year-old man who has an intellectual disability turns to you with a question. The man has a lower than average level of intelligence and has difficulty in understanding complex matters. He does not know how to read or write. He lives in a sheltered residential setting and works in a warehouse of a big clothing company. He can take care of himself independently regarding some aspects of his life, for example, he gets organized before going to work and showers independently, but he requires assistance when making food, managing his financial affairs, and other matters.

Indirect vignette I want to ask you to imagine the following scenario: Joseph is in a public place, for example, a bus station, a coffee shop or waiting in line for a movie when a 30-year-old man who has an intellectual disability turns to Joseph with a question. The man has a lower than average level of intelligence and has difficulty in understanding complex matters. He does not know how to read or write. He lives in a sheltered residential setting and works in a warehouse of a big clothing company. He can take care of himself independently regarding some aspects of life, for example, he gets organized before going to work and showers independently, but he requires assistance when making food, managing his financial affairs, and other matters.

Accepted 14 May 2015


Does type of disability make a difference in affiliate stigma among family caregivers of individuals with autism, intellectual disability or physical disability?

Developing research questions that make a difference.

Schools do make a difference.

Teachers do make a difference.

Do you make a difference?

Do stentless valves make a difference?

Direct stenting for STEMI: does it really make a difference?

Preanesthesia evaluation for ambulatory surgery: do we make a difference?

Asking questions during breast cancer consultations: does being alone or being accompanied make a difference?

Reconstructing direct and indirect interactions in networked public goods game.

Immunoadsorption versus therapeutic plasma exchange. Will fibrinogen make the difference?

Balanced versus unbalanced salt solutions: what difference does it make?

Time can make a difference.

Small things make a difference.

Deaths in intellectual disability.

Dementia in intellectual disability.

Fostering hope in adolescents with cancer: do friends make a difference?

Do echo-enhanced needles make a difference in sonographically guided vascular access?

Acute kidney injury in wasp sting-do early bicarbonate and mannitol make a difference?

The impact of thiopurines on surgical outcomes in inflammatory bowel disease: do they make a difference?

The public stigma of mental illness means a difference between you and me.

Responsiveness to Self-Report Interview Questions by Adults With Intellectual and Developmental Disability.

Editorial: No-difference Studies Make a Big Difference.

Comorbid intellectual disability.