American Journal of Orthopsychiatry 2015, Vol. 85, No. 2, 139 –144

© 2015 American Orthopsychiatric Association

University Students’ Identification of Stigmatizing Schizophrenia in Italian Newspapers Luca Pingani

Sara Evans-Lacko

Local Health Agency of Reggio Emilia, Italy

King’s College London

Valeria Del Vecchio and Mario Luciano

Sara Catellani

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University of Naples, SUN

Local Health Agency of Reggio Emilia, Italy

Arneda Hamati and Marco Rigatelli

Andrea Fiorillo

University of Modena and Reggio Emilia

University of Naples, SUN

Stigma associated with mental disorders represents one main obstacle to receive appropriate care for people with mental disorders. Compared to adults, university students have higher levels of stigmatizing attitudes toward patients with schizophrenia. The primary aim of this case-control study was to assess university students’ ability to identify stigma toward schizophrenia in Italian newspapers. Secondary aims were: a) to explore differences in stigmatizing attitudes among two different groups of university students (health professionals [HP] and nonhealth professionals [n-HP]) and b) to compare the attitudes of these two groups with those of a sample of expert psychiatrists. The electronic archives of two Italian newspapers were searched using the term “schizo” (as a word or part of it). One hundred seventy articles published between January and December 2011 were identified. Students from the HP group and expert psychiatrists had a higher ability to detect stigmatizing attitudes in newspapers. Students from the n-HP group had a higher concordance with the experts on the topics “characteristics of the article” and “services and rights.” Our findings highlight the importance of targeting university students with correct and updated information about schizophrenia and its psychosocial consequences.


the process of recovery from mental disorders (Angermeyer & Schomerus, 2012). Several different but related types of stigma are described in the literature: public stigma refers to negative attitudes or beliefs of general population toward people with mental illness (Corrigan & Watson, 2002); structural stigma is a result of laws or institutions that discriminate against people with psychiatric disorders (Corrigan et al., 2005); self-stigma or internalized stigma where people internalize negative stereotypes that can result in a decrease of self-esteem and self-efficacy (Watson, Corrigan, Larson, & Sells, 2007); felt or perceived stigma refers to the personal beliefs of patients to be stigmatized (Van Brakel, 2006); experienced stigma is about participation restriction on the part of the affected person (Van Brakel, 2006); label avoidance results in the fear to participate in mental health services to avoid a stigmatizing label (BenZeev, Young, & Corrigan, 2010; Clement et al., 2015). Mass media play a central role in the dissemination of stigma associated with mental illness, in particular newspapers, where people with mental disorders are often portrayed as violent, incompetent, unpredictable and unreliable (Carra` & Clerici, 2013). Several attempts have been made worldwide to fight stigma (Henderson, Evans-Lacko, & Thornicroft, 2013). More recently, antistigma initiatives suggest that the most effective way to reduce

espite several efforts to reduce stigma and discrimination, stigma associated with mental disorders is a major obstacle for people with mental disorders. Stigma contributes to poor social networks, social exclusion, suicide rate (Schomerus et al., 2014), income inequality, unemployment (Evans-Lacko, Knapp, McCrone, Thornicroft, & Mojtabai., 2013), and reduced help-seeking (Clement et al., 2015), thus hampering

Luca Pingani, Human Resource Development, Local Health Agency of Reggio Emilia, Italy; Sara Evans-Lacko, Institute of Psychiatry, Psychology & Neuroscience, King’s College London; Valeria Del Vecchio and Mario Luciano, Department of Psychiatry, University of Naples SUN; Sara Catellani, Human Resource Development, Local Health Agency of Reggio Emilia, Italy; Arneda Hamati, Degree Course in Psychiatric Rehabilitation, University of Modena and Reggio Emilia; Marco Rigatelli, Department of Psychiatry, University of Modena and Reggio Emilia; Andrea Fiorillo, Department of Psychiatry, University of Naples SUN. This research received no specific grant from any funding agency, commercial or not-for-profit sectors. Correspondence concerning this article should be addressed to Luca Pingani, Human Resource Development, Local Health Agency of Reggio Emilia, Via Amendola 2, 42101 Reggio Emilia (Italy). E-mail: luca [email protected] 139

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public stigma is to focus efforts on key target populations such as young people or health professionals. In fact, it has been suggested that young people and university college students have higher levels of negative attitudes toward mental disorders than adults (Yamaguchi et al., 2013), and are less likely to suggest that a friend seek mental health care if he or she would have a mental disorder (Friedrich et al., 2013). Therefore, these have been identified as important target groups (Rüsch et al., 2013). University college students from the medical field represent an important target population in the fight against stigma (Thornicroft, Rose, & Mehta, 2010), since they hold negative stereotypes toward psychiatry and mental disorders. It has been reported that 71– 89% of medical students believe that people with schizophrenia are unpredictable, and between 26% and 78% think that they are violent and dangerous and consider schizophrenia to be a chronic, progressive and incurable illness (Magliano et al., 2011, 2013; Read, Haslam, Sayce, & Davies, 2006). In addition, medical students do not consider psychiatry to be a medical discipline, or they consider it to be less scientific or precise compared with other areas of medicine (Fiorillo, Malik et al., 2013; Lingeswaran, 2010), thus, resulting in difficulties with recruitment for psychiatry (Bhugra, 2013). The views of medical students may also reflect the views of teachers and/or instructors from other health disciplines about the causes, treatments and psychosocial consequences of mental disorders. These views, rooted in the university, may also perpetuate stigma toward psychiatry and mental health professionals (Maj, 2013). Although there is a surprising lack of evidence about effective interventions to fight stigma among medical students (Kassam, Glozier, Leese, Henderson, & Thornicroft, 2010), protest, education, and contact seem to be the most effective strategies (Corrigan et al., 2001). Protest, which aims to eliminate negative stereotypes in contexts such as public statements, media reports, or advertisements (Rüsch, Angermeyer, & Corrigan, 2005), may be useful for the suppression of prejudice but does not necessarily provide a positive alternative that can replace the negative stereotype. The second strategy, education, is often characterized by the provision of evidence-based information about specific mental illnesses and their treatments, or by demonstrating how certain stigmatizing myths (e.g., “most murderers suffer from schizophrenia”) do not correspond with the truth (e.g., “People with schizophrenia are more often victims rather than perpetrators of violence”). This approach may be more effective among people who have met people with mental disorders (Rüsch et al., 2005). The strategy of direct contact with people with mental disorders has been shown to be an effective way to fight stigma (Evans-Lacko, Malcolm et al., 2013), by reducing anxiety and allowing people to check “in vivo” the invalidity of one’s own prejudice (Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012). A recent meta-analysis suggests that education and contact are both very effective for reducing stigma, and that contact is most useful among adults, while education was for adolescents (Corrigan, Morris, Michaels, Rafacz, & Rüsch, 2012). In a recent systematic review, Yamaguchi (Yamaguchi et al., 2013) summarized the main types of antistigma interventions directed at university students: social contact and education (video-taped), educational texts, watching movies and educational role-plays. Several hypotheses have been proposed to explain the lack of effective interventions for medical students (e.g., too much em-

phasis is given on the “medical model” or “biological knowledge”). Additional research suggests that medical students believe that patients are responsible for their mental disorders (Thornicroft et al., 2010), and that mental disorders are chronic and noncurable illnesses that could seriously affect one’s ability to work (Papish et al., 2013). This study aims to: a) determine whether medical students are more likely to recognize stigmatizing attitudes toward schizophrenia in newspapers compared to nonmedical students using a group of experts as a gold standard; b) assess agreement among members of each of the two groups of students in relation to recognizing stigmatizing attitudes; and c) analyze the agreement between the two groups of students in recognizing the presence of stigmatizing attitudes toward schizophrenia in Italian newspapers.

Method Participants and Study Design This is a case-control study that assesses the recognition of stigma in relation to schizophrenia between three groups of respondents. The first group comprised four students training to become health professionals (HP) in Psychiatric Rehabilitation. This is a 3-year undergraduate course that is taught within the Faculty of Medicine and Surgery (Pingani et al., 2013). The second group (n-HP) included four undergraduate students in a nonmedical area (journalism, law, economy and pedagogy). Students were invited to participate in the study by an e-mail invitation. The third group comprised experts in the mental health field: a PhD student in Psychiatry, an Associate Professor of Psychiatry and a Full Professor of Psychiatry (see Table 1).

Newspaper Articles Among the five most read newspapers in Italy, we considered the first (Corriere della Sera) and the last (La Stampa), according to the number of copies sold per day. We searched an electronic archive of these two Italian newspapers for articles containing the term “schizo” (as a word or part of a word). One hundred seventy articles were identified between January 1, 2011 and December 31, 2011. For every identified article, the following information was collected: day and month of publication, number of words in the title and complete text containing the term “schizo.”

Assessment Instrument All study participants were asked to read the articles and to complete a questionnaire (Australian Department of Health & Aged Care, 1999) composed of nine questions (see Table 2) grouped in four categories: a) characteristics of the article; b) language used by the journalist; c) presence of stigmatizing attitudes in the article; d) description of the rights and services which could be of benefit to a person with a mental disorder. For each question, a “Yes” or “No” answer was possible.

Statistical Analysis Each group of students’ responses was compared to the gold standard (i.e., responses agreed by mental health professionals) for



Table 1. Sociodemographic Characteristic of the Three Groups (Health-Professional Group, Nonhealth-Professional Group and Expert Group)

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Health-professional group Psychiatric rehabilitation Psychiatric rehabilitation Psychiatric rehabilitation Psychiatric rehabilitation Nonhealth-professional group Journalism Law Pedagogy Economy Expert group PhD in Psychiatry Associate professor of psychiatry Full professor of psychiatry

22 23 21 22 22 23 21 24 32 38 64


Mean age: 22 SD: ⫾0.82

Mean age: 22.5 SD: ⫾1.29

Mean age: 44.67 SD: ⫾17.01

concordance. Additionally, the within-group agreement was assessed to investigate the homogeneity of responses among each group. The level of agreement between the groups and the gold standard was assessed using Cohen’s kappa coefficient and analyzed using the published guidelines of Fleiss: ⬍0 poor agreement, 0.01– 0.20 slight agreement, 0.21– 0.40 fair agreement, 0.41– 0.60 moderate agreement, 0.61– 0.80 substantial agreement, 0.81–1.00 almost perfect agreement (Fleiss, 1981). The delta (⌬) was calculated to test the differences in agreement between the two groups of students. The Statistical Package Social Sciences (SPSS) version 13.0 and STATA version 10.0 were used for data analysis.

Results Sixty-one articles from La Stampa and 108 from Corriere della Sera were identified and evaluated. Information about the collected articles is described in Table 3.

Agreement Between the Two Groups and the Expert Group The level of agreement between each of the two groups and the normative response made by the group of experts (concordance of

Female Female Female Female

Female: 4 (100%)

Male Female Female Female

Male: 1 (25%) Female: 3 (75%)

Male Male Male

Male: 4 (100%)

correct answers, %) is described in Table 4. The healthprofessional group showed greater concordance with the gold standard in the questions about the presence of stigmatizing attitudes (57.59% vs. 36.09%). The agreement with the expert group was more or less the same for the two groups (72.78% vs. 72.19%) for the set of questions “Language used by journalists.” Students from the nonhealth group obtained a greater concordance in “characteristics of the article” (65.98% vs. 59.17%) and in “services and rights” (93.79% vs. 89.98%) categories.

Agreement Between and Within the Student Groups Using Fleiss’ encoding for K value, there is only a slight within-group agreement for the Health-Professional Group for the questions “Characteristics of the article” and “Presence of stigmatizing attitudes” (K ⫽ 0.14 and 0.11, respectively). Also for the health-professionals group, there is a moderate and substantial agreement for the questions about “Language used by journalists” (0.45) and “Services and rights” (0.65). The nonhealthprofessionals group had a slight agreement for the first group of questions (“Characteristics of the article”) with a K value of 0.02, a fair agreement (0.34) for the group of questions about

Table 2. Questions to Assess the Identification of Stigmatizing Attitudes in Newspaper Articles Categories Characteristics of the article

Language used by the journalist

Presence of stigmatizing attitudes in the article

Description of the rights and services which could be of benefit to a person with a mental disorder

Questions Is the headline inaccurate or inconsistent with the focus of the article? Is the headline or content unnecessarily dramatic or sensational? Is the language outdated, negative or inappropriate? Is the medical terminology inaccurately or not in the correct context? Does the article reinforce negative stereotypes about mental illness? Does the article emphasize the illness rather than the person? Does the article imply that all mental illnesses are the same? Does the article provide information about sources of help or referral to mental health services? Does the article disclose that a particular individual has a mental illness, identifying the person by name?



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Table 3. Main Characteristic of Collected Articles

Publishing page Front page Other pages Publication month January February March April May June July August September October November December Day of publication 1–10 11–20 21–31 Used terms Schizophrenia/Schizophrenias Schizophrenic/Schizophrenics Schizoid Schizophrenically Number of words in the title Number of words in the text of the article

“Language used by journalist” and a moderate agreement (0.47) for the questions on “Services and rights.” The nonhealthprofessionals group had a negative K value (⫺0.10) for the questions about the “Presence of stigmatizing attitudes.” Overall, the health-professional group obtained higher agreement with the gold standard for each set of questions. The difference in agreement between the groups ranges from a ⌬ value of 0.11 (“Language used by journalists) to 0.21 (“Presence of stigmatizing attitudes”; see Table 5).

Discussion This study investigated the differences related to the awareness and knowledge of stigma toward people with mental illness in undergraduate students from medical and nonmedical faculties. The students from the medical faculty were more likely to identify stigmatizing attitudes and showed a higher level of agreement among its members.

Corriere della Sera N (%)

La Stampa N (%)

14 (12.96) 94 (87.04)

10 (16.39) 51 (83.61)

9 (8.33) 8 (7.41) 6 (5.56) 11 (10.19) 9 (8.33) 8 (7.41) 12 (11.11) 5 (4.63) 7 (6.48) 15 (13.89) 10 (9.26) 8 (7.41)

5 (8.20) 5 (8.20) 5 (8.20) 8 (13.11) 6 (9.84) 6 (9.84) 5 (8.20) 3 (4.92) 3 (4.92) 3 (4.92) 8 (13.11) 4 (6.56)

31 (28.70) 31 (28.70) 46 (42.59)

21 (34.43) 18 (29.51) 22 (36.07)

58 (53.70) 49 (45.37) 0 1 (0.93) Mean (SD)

30 (49.18) 27 (44.26) 4 (6.56) 0 Mean (SD)

8.14 (⫾3.08) 642.33 (⫾329.82)

18.10 (⫾9.60) 596.54 (⫾247.39)

By comparing the level of agreement of the two student groups with the expert group the differences in agreement between the two groups were minimal, ranging from 0.59% to 6.81%, with the only exception of the category “Presence of stigmatizing attitudes” for which the difference was more evident (21.50%). This finding may be the result of the specific curricula of the two groups, with sociology, psychology, and anthropology being included in the curricula of the HP students and not in that of nonhealthprofessionals students. Courses in sociological, historical, and theoretical aspects of stigma are included in the curriculum of the health-professionals group only. The nonhealth-professionals group showed a higher ability to identify violations of patients’ rights compared to the healthprofessionals group. This result might be explained by the fact that the n-HP group was mainly constituted by students attending journalism, law, economy and pedagogy degrees, where basic knowledge about national regulations and laws is provided.

Table 4. Agreement Between the Two Student Groups and the Expert Group

Health-professional group Nonhealth-professional group

Characteristics of the article (Questions 1 and 2) (%)

Language used by journalist (Questions 3 and 4) (%)

Presence of stigmatizing attitudes (Questions 5, 6, 7) (%)

Services and rights (Questions 8, 9) (%)

200/338 (59.17) 223/338 (65.98)

246/338 (72.78) 244/338 (72.19)

292/507 (57.59) 183/507 (36.09)

294/338 (89.98) 317/338 (93.79)



Table 5. Within-Group Agreement Among the Two Groups of Respondents (Health-Professional Group and Nonhealth-Professional Group) Health professional group

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Characteristics of the article Language used by journalist Presence of stigmatizing attitudes Services and rights

Nonhealth-professionals group



⌬ (HPG-nHPG)



0.14 0.45 0.11 0.65

Slight agreement Moderate agreement Slight agreement Substantial agreement

0.12 0.11 0.21 0.18

0.02 0.34 ⫺0.10 0.47

Slight agreement Fair agreement Poor agreement Moderate agreeement


In terms of within-group agreement, the agreement among members of the health-professionals group was greater than that of the nonmedical-faculty group; it may be that a homogeneous curriculum facilitated greater uniformity in the assessment of articles. In two categories (“Presence of stigmatizing attitude” and “Services and rights”), the differences between the healthprofessionals group and nonhealth-professionals group was particularly high. These differences might be explained by different knowledge among the two groups: Students who are in medical training may have more training about how to deduce clinical, health, or services’ information from articles appearing in the media. The HP group showed a higher internal agreement for the category “Services and rights” (0.65) rather than for the category “Presence of stigmatizing attitudes” (0.11). This might be because information on patients’ rights and on delivery of psychiatric care were less subjective than the questions about stigma. On the contrary, the detection of stigmatizing attitudes in Italian newspapers can be influenced by several personal and contextual factors, such as cultural, political and educational issues, and therefore can present a significant heterogeneity. Moreover, the fact that a low level of agreement for the category “Presence of stigmatizing attitudes” (⫺0.10) was also detected in the n-HP group, suggests differing levels of knowledge of this phenomenon and that this may be a particular gap in this population. This study has some limitations that need to be acknowledged, such as the small sample size and the self-selection of participants. Therefore, our findings cannot be considered representative of the national student populations. Another limitation is that n-HP students were purposely selected and students from other degree courses are not represented. Finally, although we have detailed responses from all participating students (all study participants answered 1,530 questions and read approximately 170 newspaper articles), this study is exploratory in nature. However, difficulty of recruiting a sample of assessors who were available to answer 1,530 questions and to read such a high number of newspaper articles should be considered. Despite these limitations, this is one of the first studies assessing attitudes of university college students to identify stigmatizing attitudes in newspapers, and can be considered a starting point for larger studies.

Conclusions This study highlighted differences in the identification of stigmatizing attitudes among students from medical and nonmedical faculties. In particular, students from a medical faculty showed a

higher reliability with experts compared to their peers from a nonmedical faculty. Therefore, our findings support the need for all university students to have access to relevant, factual and up-to-date information about mental disorders and the consequences of stigma and discrimination. This, in turn, could improve access to care and promote social inclusion of persons with mental disorders, which are among the top priorities according to European stakeholders active in the mental health enterprise (Fiorillo, Luciano et al., 2013). Keywords: stigma; schizophrenia; agreement; college student; attitude; knowledge

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University students' identification of stigmatizing schizophrenia in Italian newspapers.

Stigma associated with mental disorders represents one main obstacle to receive appropriate care for people with mental disorders. Compared to adults,...
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