The impact of mental health stigma

Table of Contents

Chapter Two:  Review of Literature………………………………………………………………………………….. 3


Don't use plagiarized sources. Get Your Custom Essay on
The impact of mental health stigma
Just from $9/Page
Order Essay


What is Stigma?………………………………………………………………………………………………….. 4

History of Mental Help-Seeking Habit among African Americans……………………………… 7

The Impact of Mental Health Stigma…………………………………………………………………….. 10

Stigma and Attitudes to Mental Illnesses in the United States of America………………… 15

Stigma and Attitudes to Mental Illnesses across various Cultures……………………………… 15

References……………………………………………………………………………………………………………………. 17

Appendices…………………………………………………………………………………………………………………… 26


Chapter Two:
Review of Literature


Literature reports indicate yearly a prevalence rate of 30% for mental health illnesses, with about two-thirds of this not getting any treatment (Andrade et al., 2013; Sharma et al., 2008; Thornicroft, 2008).   A combination of factors is responsible for this.  It is argued that mental health seems to be a theme that has not attracted the needed attention of public health settings and discussions (Thornicroft, Rose, & Kassam, 2007).  This unarguably impacts on the general health quality of the individuals affected (Saxena, Thornicroft, Knapp, & Whiteford, 2007; Schwartz & Meyer, 2010).  This situation is much worse for neglected populations, especially women and children within the socio-cultural and ethno-religious contexts, across different countries (Schwartz & Meyer, 2010; Spencer & Chesler, 2007).

Several studies have been carried out to design a framework for understanding how gender, racial, religious or other forms of identity and the present-day socio-political contexts in which our environments are shaped affect the mental health of minorities in the United States and many other parts of the world (Abu-Ras & Suarez, 2009; Evans-Lacko, Brohan, Mojtabai, & Thornicroft, 2012; Govender & Penn-Kekana, 2008, 2009; Hatzenbuehler, McLaughlin, Keyes, & Hasin, 2010; Laird, Amer, Barnett, & Barnes, 2007; Lasalvia & Tansella, 2008; Zur & Nordmarken, 2013).  These studies as well are increasingly checking the quality of health care these minorities get (Laird et al., 2007).

What is Stigma?

“Stigma” as a term was first used by the ancient Greeks to represent the marks lanced onto slaves as a sign of ownership and of course of inferior social rank (Thorne, 2013).  In ancient Greece, stigma was regarded as a distinctive mark burned or incised into the skin for the purpose of identifying slaves or criminals (Thorne, 2013).  But in the present day, the definition no longer alludes to flesh branding, but rather any mark placed on the body which detaches from the person’s character or reputation, or simply a mark representing something that is abnormal or not standard (Thorne, 2013).

In the modern world, the term stigma was first applied in 1962 (Brohan, Slade, Clement, & Thornicroft, 2010; Goffman, 2009).The modern day “stigma is an illuminating excursion into the situation of persons who are unable to conform to standards that society calls normal” (Goffman, 2009, p. 154).  Goffman states that stigma is a reflection of a social attitude or response to mental problems that is totally demeaning and a locus of social humiliation.  Basically, stigma also echoes an inconsistency between an individual’s “virtual social identity”, which is the societal beliefs about a particular individual, and the individual’s “actual social identity”, which is regarded as any qualities that a person could be demonstrated to own (Goffman, 2009, p. 138).   Goffman (2009) explains further that stigma heightens any attribute which dishonors a particular individual and can provoke a set of inaccurate assumptions about such an individual’s character and capabilities, often causing various degrees of discrimination.

Stigma can rise of a person having an attribute, mostly less desirable or bizarre, that somewhat distinguishes that person from others, thus reducing the individual in the society from a whole and normal person to a stained, discounted one (Goffman, 2009).  Stigma inherently dehumanizes and condenses an individual’s social value because he/she is judged as being “marked”, blemished, and below average.  A stigmatized trait always differs from what a society regards as normal, and this ultimately triggers the society’s response which may come in the form of interpersonal or combined reactions that seek to isolate, treat, threaten, correct, or punish any individual engaged in such behavior.

Though much agreement exists of what stigma means, there is lack of a single, uniform theory.  In other words, it seems there is significant agreement on the notion that stigma means any kind of mark that leads to humiliation or disgrace and thus sets that individual or group apart from others.  It is also well established that stigmatization carries with it multi-faceted and multi-layered strength and impact, which are always damaging and negative (Goffman, 2009).

Perceptions of Stigma:

The beliefs about or perceptions of stigma, attitude, and cultural related issues are barriers for mental health care in the African American community (APA, n.d.; Evans-Lacko et al., 2012; Govender & Penn-Kekana, 2008, 2009; Jablensky & Kendell, 2002; Shives, 2008).  In addition, culturally rooted, religious beliefs and practices have been identified as barriers for this community (Levin, Chatters, & Taylor, 2005; Neighbors et al., 2007; Thornicroft, 2008; Waldron, 2010).  Due to the historical roles of teacher, preacher, and counselor of African American pastors; it is also important to understand their perceptions of stigma and attitudes toward mental illness and professional mental health services, and their help-seeking behaviors (Neighbors et al., 2007).

As already established above, literature implicates many factors affecting help-seeking habit for mental illness among various populations, but self-stigmatization leading to social withdrawal remains a constantly stated theme by many authors (Daradkeh, Eapen, & Ghubash, 2005; Eapen & El-Rufaie, 2008; Jaspal & Cinnirella, 2010; Jaspal & Siraj, 2011; Saxena et al., 2007).  As a result of this, it is important to do a thorough examination of the concern of self-stigmatization among specific populations.  Therefore, in the case of the proposed study, the role of self-stigma on the help-seeking habits of college-aged African American females residing in the United State will be examined.  More specifically, this study will also check the relationship between the levels of self-stigma and an awareness of a pastor’s primary use of scripture
and prayer as counseling tools. Consequently, it will examine if
there is a relationship between African American college aged females
who are aware of their pastors’ primary use of prayer and scripture as
counselling tools and their socioeconomic status, denominational
affiliation, or previous experience with mental illness

Many studies have been conducted to examine the correlation between self-stigma and seeking mental health services. There has been an abundance of literature which attempts to adequately explain the relationship between self-stigma and seeking mental health services.

In doing this literature review, it is hoped that a more thorough understanding of the relationship between self-stigma about seeking mental health services will be reached. This literature review also critically evaluates and compares evidence and research done on this issue so as to carry out a more comprehensive research.

Broader Stigma Overview explained:

psychological counselling for levels of therapy

                              Incidences of Stigma in the United States

A stigma outbreak is a situation where very many people have stigma regarding mental health.


History of Mental Help-Seeking Habit among African Americans

According to history, experts and the American society generally defined mental illness in more tapered and extreme terms than they did for psychiatry in the 1950s.  At this time, it was common to fear and reject victims of mental illness (Phelan et al., 2000).  The picture so far painted in literature seems to suggest that mental illness definitions may have been stretched and that rejection and negative labels of victims may have reduced since that time.  However, the dearth of comparable data between 1950s and late 1990s prevented scholars from drawing firm conclusions about whether negative labels and rejection attitudes towards mental victims was reducing or increasing.  It was because of these questions that prompted the 1996 General Social Survey Mental Health Module to look further into the meaning of mental illness that was first asked of a nationally representative sample in 1950.  When compared, the results of 1950 and 1996 revealed that mental illness conceptions have expanded to a certain extent over the period under review.

The literature search revealed that self-stigma pose a significant problem for public health in the United States.  Although much is understood about the mechanisms of transmission, symptoms, etiologies, and treatments of individual cases, much less is known about the mechanisms involved in self-stigma disease outbreaks.  Research related to specific pathogens suggests that outbreaks are preventable, but the effectiveness of specific intervention and prevention strategies was not apparent.  Recently, there has been an emphasis on the need for more research related to outbreaks, with particular emphasis on updating food safety regulations.  Before regulations and prevention strategies can be improved, this study addresses the concern that more research must be conducted on how location and setting, including season, are related to outbreaks.  This chapter summarizes relevant background information related to self-stigma illness, including the frequency of outbreaks and the characteristics of pathogens examined in this study.  In order to exhibit the urgency of this study, this chapter demonstrates the importance of location and setting and its relevance to prevention and regulation.

A greater amount of nonpsychotic conditions have been included, while the perceptions that people with mental disorders are violent or scary were increasing significantly, instead of decreasing (Phelan et al., 2000).  However, this increase was observed only in participants who regarded mental illness as psychosis.  Among such participants category, the percentage who tagged a person with mental disability as being violent rose by approximately 250% between 1950 and 1996 (Phelan et al., 2000).  Based on these findings, Phelan et al. (2000) argues the possibility of a real, quantum leap toward recognition of the fact that anyone of “us” is vulnerable to the various forms of mental disorder, but that those suffering from psychosis are actually a “them” “who are more feared than they were half a century ago” (Phelan et al., 2000, p. 118).

Literature has shown that perceived racism seems to be connected with adverse psycho-physiological outcomes, albeit researchers argue that these findings are inconclusive (Pieterse, Todd, Neville, & Carter, 2012). To this end, it is argued that racism may not be a major causal factor for mental illness among African American blacks and it may not be linked to the help-seeking habit as well (Pieterse et al., 2012).

Since the eighteenth century socio-political revolution, the western political milieu has metamorphosed into a level where inequalities between persons or groups are no longer taken for granted (Baynton, 2013).  Yet differential with unequal treatment has persisted in the country, though regarded “incumbent in modern societies to provide a rational explanation for such treatment” (Baynton, 2013, p. 17).  Age, gender, race, ethnicity, religion and disability are the commonest rational grounds for discrimination in many societies.  While a lot of research efforts have been put into studying the rationality of differential and unequal treatment with regard to identity, such as gender, ethnicity, race, and religion, historians and scholars generally have done little or nothing in the case of disability (Baynton, 2013).  Essentially, Baynton (2013) argues that disability has hardly been a theme of historical inquiry.

Historically, the coexistence of disability and any of the other factors mentioned above usually constitutes a strong basis for rationalizing inequalities.  In other words, the concept of disability has indeed not only created a justification for treating disabled people unequally but also to substantiate discrimination against other identities by attaching disability to them.  Between the nineteenth and twentieth centuries, disability was a major concern in the three hot citizenship debates: African American freedom and civil rights, women’s suffrage, and immigration restrictions (Baynton, 2013).  Basically the moment an inquiry is put in its direction, disability seems historically ubiquitous, albeit visibly missing in the written history so far. And any time a historian or scholar focuses on disability, he or she typically treats it purely as peculiar misfortune or stigma to be censured and a tag to be repudiated, rather than as a questionable construct of culture that should be studied deeper (Baynton, 2013).  This attitude definitely holds implications for the victims of mental disability, as they feel helplessly stigmatized and develop unwilling help-seeking attitudes.

The evidence suggests the similarities exist between specialist practices for stigma (Murry et al., 2011). These differences reflect the scope of the different roles arising from their practice environment. The two types of specialist roles are located in acute care settings, where they are characterized by technical skills, combined with management and medical professionals’ roles, with some Issues in practice for stigma (Murry et al., 2011). A difference also appears to exist between the different roles of America and Africa in terms of the levels at which they practice. Specialist roles (both specialist Americans and Africans) are content specific, technical, related to specific clinical problems and can be updated by continuous professional development. By comparison, the stigma role in healthcare is grounded in practice and reflection on that practice for the purpose of further development in stigma. These differences might suggest that, although Specialist roles are concerned with advancing practice, the process of reflection inherent in the African-American role drives this to a higher level of practice (E. C. Ward & Besson, 2012).

Although mental illness associated stigma and unwilling help-seeking habit cuts across all races, literature indicates higher levels of stigma and unwilling help-seeking habit among certain races, such as the African American, than the others (Hunter & Schmidt, 2010).  According to Hunter and Schmidt (2010), historically there are three particular beliefs or attitudes that are associated with the African Americans’ sociocultural experiences: racism awareness, mental illness stigmatization, and salience of physical disorders.  And it is the combination of these beliefs that influences their help-seeking decisions (Conner et al., 2010; Hunter & Schmidt, 2010).

An expansive body of research supports a characteristic help-seeking habit and underutilization of mental health services by African Americans due to associated stigma (Conner et al., 2010; Hunter & Schmidt, 2010; Lindsey, Joe, & Nebbitt, 2010; Livingston & Boyd, 2010; Phelan et al., 2000; Snowden, 2012).

Mental Illness in African American Women:

Literature reveals that women generally are still not likely to have access to health care as much as men (Kronfol, 2012).  More often than not, women’s mental health issues are not even recognized as health issues, and that is why the “turn to God through prayer” attitude seems to be more common among women than men (Thornicroft, 2008, p. 16).  Naturally speaking, men-women inequality practically exists almost everywhere in the world, though it is more rampant in certain places, such as the Middle East, than the other places, such as the United States (Evans-Lacko et al., 2012).

Though the United States is a country where equal rights are strongly advocated, studies have continued to suggest that women are still predisposed to some level of gender inequality in virtually every aspect of life, including health (Govender & Penn-Kekana, 2008, 2009; Ridgeway, 2012; Williams, 1995).  While gender inequality and discrimination may be very rampant in many countries around the world, the United States seems to have improved considerably.  Decades of research studies have documented gender health inequalities across different continents and countries, and this theme has in recent times snowballed into policy targets in many developed countries, especially the United States.  Bleich, Jarlenski, Bell, and LaVeist (2012) in their study describe the time drifts in health inequalities using sex, ethnicity (or race), and socioeconomic status, efforts to lessen health inequalities, and level of success or progress made to eradicate inequalities within the health sectors in the United States, United Kingdom, as well as other Organisation for Economic Co-operation and Development (OECD) countries.  According to their result, the US time-trend data showed a contraction of the gap between the top best groups and top worst-off groups in certain indicators of health, such as life expectancy, but a widening of the gap in others, such as diabetes prevalence.

Though not many studies have been conducted to examine these women’s mental health challenges within the United States, there are strong indications of higher prevalence of mental health illnesses among the minority women than their men counterparts almost in every part of the world (Ghubash, El-Rufaie, Zoubeidi, Al-Shboul, & Sabri, 2004; Hamdan, 2009; Kronfol, 2012; Lawton & Schulte, 2012; Malmusi, Borrell, & Benach, 2010; Saxena et al., 2007; Sellers, Cherepanav, Hanmer, Fryback, & Palta, 2013; Thornicroft et al., 2007; Thornicroft, 2008; Vázquez-Barquero et al., 1992).

Mental health stigma

As discussed earlier, there are various conceptualizations and rationalizations for mental stigma, yet there is little doubt that mental illness stigma has substantial corollaries and many damaging effects, both to the affected person and his or her close friends as well as family members (Boyd, Katz, Link, & Phelan, 2010; Lindsey et al., 2010; Livingston & Boyd, 2010; Werner, Mittelman, Goldstein, & Heinik, 2012).

A study by Phelan et al. (1998) underscored the impact of mental health stigma on family members by enrolling 156 parents as well as spouses of psychiatric patients who were on the first-time admission.  Their findings revealed that 50 per cent of the participants hid the details of their relatives’ hospitalization from others. Also, their findings showed family members of a mentally ill patient were more unlikely to reveal the knowledge of the mental health condition if:

  • They did not cohabit with their mentally ill relative,
  • Their relative was female, and
  • Their relative had more severe undesirable symptoms.

In essence, the findings lend credence to the existence of a certain level of shame and humiliation that can afflict close members of the family.

According to Werner et al. (2012), the family members of a person having a stigmatized illness experience stigma from three dimensions:

  • Stigma from caregiver,
  • Stigma from lay public, and
  • Structural stigma.

According to research, stigma from the perspective of caregivers originates from the consciousness of an increased burden of care-giving to mentally ill patients as caregivers spend more time and resources treating mentally ill patients than they do when handling many other categories of medical conditions (Bell et al., 2010; Werner et al., 2012).  But, the impact of stigma on caregiver burden among the individuals whose relatives suffer a mental disease has not been theoretically and empirically tested, and that was the reason Werner et al. (2012) examined the connection between stigma and caregiver burden prediction for Alzheimer’s disease.  Werner et al. (2012) employed a structured face-to-face interview method with 185 adult child caregivers for individuals suffering from Alzheimer’s disease.  Their results revealed that caregiver stigma variables (shame and decreased association with caregiving) majorly enhanced the caregiver burden prediction.  As a result, Werner et al. (2012) concluded that for Alzheimer’s disease, caregiver stigma escalates caregiver burden, recommending that this knowledge can be utilized in psychosocial interventions to specifically target stigmatic beliefs so as to lessen caregiver burden.

Corrigan, Kerr, & Knudsen’s (2005) explanatory model reasons that stigma is capable of denying individuals with mental illness stigma of two predominantly imperative opportunities in life.  The first is getting a decent, competitive employment while the second is living an independent life in a safe, private and happy home.  Their argument is rooted in the problems that are often unavoidably encountered in housing and work when an individual suffers a certain mental health condition.  For instance, there are certain mental health conditions that cause compromised social and surviving skills needed to keep pace with the rapid changes that occur in a competitive workforce and the demands of an independent living.  The social status of property-owners and employers of labor who believe the stereotypes about mental health disorders may respond in an intolerant and discriminatory manner.  A study conducted by Kaye (2012) examined the impacts of a psychiatric disorder and treatment support services on discrimination as it relates to housing.  The findings from Kaye’s (2012) study showed that public stigma towards people with psychiatric illnesses still constitute a barrier to having access to decent and affordable housing despite:

  • Literature evidence that identifies stable and decent housing as a major factor in recovery from psychiatric problems;
  • The establishment of public programs and policies to provide people with psychiatric disabilities resources and treatment support to assist people secure and maintain choice housing.

Also, stigma can distress individuals with mental health conditions who are involved with the system of criminal justice (Markowitz, 2011).  Mental illness criminalization ensues when an individual with a mental health condition is handled by the police, courts of law and jails, as opposed to the appropriate mental health system (Markowitz, 2011; Silverstone, Krameddine, DeMarco, & Hassel, 2013).  This argument comes up because of meager funding of mental health services and somewhat harsh crime policies (Markowitz, 2011).  Researchers maintain that the public’s burgeoning prejudice towards criminals at large has triggered harsher laws and hampered effective planning of treatment for offenders who are mentally ill (Freudenberg, Daniels, Crum, Perkins, & Richie, 2008; Markowitz, 2011; Morabito et al., 2010; Silverstone et al., 2013).  Comparative studies on the arrest rates of the general American public have revealed that individuals presenting mental health illnesses and/or symptoms are more vulnerable to police arrest than others (Freudenberg et al., 2008).  In fact, Steadman, McCarty, and Morrissey (1989) contend that this discriminatory process persists should the arrested individual gets jailed; their study revealed that such individuals spend more time in incarceration than those without a mental health condition.  Exposing an individual to such discriminatory practice will most definitely have several major longer term consequences on his/her life (Steadman et al., 1989).  Furthermore, researchers have continued to warn that treating mentally ill people like criminals has serious consequences not only for their lives, freedom, and welfare, but also for the community at large as such community will inadvertently lose potential contributions from such citizens (Andrews & Bonta, 2010).

Stigma and Attitudes to Mental Illnesses across various Cultures: Role of stigma in cultures

Many people with mental disorders such as schizophrenia battle with stigma instigated by other people’s knowledge or understanding, attitudes, and behavior, which may result in destitution, social ostracism, and inferiority of life.  Thornicroft, Brohan, Rose, Sartorius, & Leese (2009) proved this by attempting to define the nature, course, and severity of expected and experienced discrimination recounted by schizophrenic patients in their research.  They embarked on a cross-sectional survey focusing on 27 countries by employing face-to-face interviews with a total of 732 schizophrenic patients.  They measured discrimination using a newly endorsed discrimination and stigma scale (DISC) that is designed to produce the following three sub-scores:

  • Discrimination with positive experience;
  • Discrimination with negative experience; and
  • Discrimination with anticipation.

Their findings revealed discrimination with negative experience in 47 per cent (344) of 729 participants in friends making or keeping, in 43 per cent (315) of 728 from members of their families, in 29 per cent (209) of 724 in getting a job, 29 per cent (215) of 730 in securing a job, and in 27 per cent (196) of 724 in bosom or sexual relationships.  Discrimination with positive experience was uncommon while discrimination with anticipation affected 64 per cent (469) in job application, education, or training and 55 per cent (402) in searching for a close relationship; 72 per cent (526) felt there was a need to hide their diagnosis.  More than 25 per cent of participants expected discrimination for seeking for a job and close interpersonal relationships when they experienced no discrimination at all.  Thornicroft et al. (2009) then concluded that the levels of both anticipated and experienced discrimination remain constantly high across various countries among individuals with mental disabilities.  There are several other cross-country and cross-racial and fairly globally representative research findings that add weight to these findings (Brohan, Elgie, Sartorius, & Thornicroft, 2010; Brohan, Slade, et al., 2010; Evans-Lacko et al., 2012; Hampton & Sharp, 2013).  As a result, Thornicroft et al. (2009) recommend that actions such as disability discrimination legislations might continue to be ineffective if interventions to bolster the self-esteem of mentally ill people are not considered globally.

Stigma in USA discussed with examples

Ever since the release of the U.S. Surgeon General’s ground-breaking report on Mental Health in 1999, a substantial number of research studies have been conducted and validated that stigma regarding mental illness and professional mental health care is a major barrier that affects the African American community (Snowden, 2012; Vogel, Wade, & Hackler, 2007).  The proposed research study is aimed at exploring the level of self-stigma about seeking mental health services and the coping strategies employed by college-aged African American females.  Therefore, it is important to examine the findings regarding African Americans beliefs about mental illness and mental health treatment, and perceptions of stigma from previous research.

Ward and Heidrich (2009) investigated African American women’s beliefs about mental illness and barriers to seeking mental health treatment were investigated in a qualitative study using the Common Sense Model (CSM).  It was Howard Leventhal who developed the CSM based on his self-regulation theory, which suggests that a persons’ beliefs and expectations about illness is based on their personal evaluation of a situation (McAndrew et al., 2008).  The CSM specifically proposes that an individual’s knowledge, views, thoughts, and attitudes are informed by their experience, stories from friends and family, and education (Earlise C Ward & Heidrich, 2009).

Fifteen African American women participated in face to face semi-structured interviews using questions that were developed around the seven constructs of the CSM, which include identity, cause, timeline, consequences, cure or control, illness coherence, and emotional representation.  The participants believed discrimination toward people with mental illness, and lack of knowledge about mental illness and where to find mental health services were barriers for seeking mental health care (Earlise C Ward & Heidrich, 2009).  They also believed that stigma towards mental illness because of negative cultural perceptions and embarrassment served as barriers for African Americans’ willingness to seek mental health services (Earlise C Ward & Heidrich, 2009).

Stigma in women of America

The small sample that only included women limited the ability to generalize the findings.  However, the CSM provided a framework that could be replicated for additional studies to increase the level knowledge regarding African American’s beliefs about mental illness and mental health services (Earlise C Ward & Heidrich, 2009).  The previous study was replicated in an exploration of African American men’s beliefs and perceptions of stigma about mental illness, and barriers for seeking help (E. C. Ward & Besson, 2012).  Due to the limited amount of research about the beliefs of African American men; an explorative descriptive qualitative approach was utilized, which allowed the researchers to increase the level of flexibility with their questions.  The goal was to gain the trust of the research participants to verbally share their perspectives and stories (E. C. Ward & Besson, 2012).  Seventeen men in a suburban city in the Midwest with a 6% population of African Americans participated in the study.  Purposeful and snowballing sampling was employed to recruit African American male participants with and without a diagnosis of mental illness (E. C. Ward & Besson, 2012).  The sampling approach was appropriate because African American males with and without mental illness diagnoses were the target population for the study.

The CSM also informed the interview question and data analysis in this study (E. C. Ward & Besson, 2012).  Many of the participants were optimistic about seeking treatment for mental illness and did not endorse the idea of stigma towards mental illness and seeking mental health treatment (E. C. Ward & Besson, 2012).  These findings were inconsistent with those that were revealed in the previous study with female participants.  The inconsistency implies that there is a difference between African American women and men’s beliefs and perceptions of stigma about mental illness, and barriers for seeking help.

Although the CSM informed the interview questions and data analysis, questions specifically related to stigma were not asked in either study.  This may have contributed to the low endorsement of stigma towards mental illness and seeking mental health treatment in the latter study (E. C. Ward & Besson, 2012).  The failure of asking specific questions related to stigma could also be viewed as a weakness in both studies. The small sample and focus on African American men, limited the generalizability of these findings (E. C. Ward & Besson, 2012). The two studies using the CSM are not specifically related to the targeted population of the proposed research; however, they have contributed to the body of knowledge and provide some insight about African American women and men’s beliefs and perceptions of barriers about mental illness and treatment.


Healthcare Systems:

Persons having mental health disorders may also be distressed within the health care systems.  According to studies conducted within the American health system, mentally ill people get fewer medical services and help than others, with lesser chances of getting the same level of insurance welfares as their mentally healthy colleagues (Schoen, Osborn, How, Doty, & Peugh, 2009). For example in a study conducted by Druss, Bradford, Rosenheck, Radford, and Krumholz (2000) within the acute care US nongovernmental hospital facilities also explored the forms of medical procedures applied after myocardial infarction.  In a total sample of 113,653, their findings showed that individuals having co-morbid psychiatric illness were considerably less likely to go through percutaneous transluminal coronary angioplasty, which is a cost-saving and less traumatic substitute to bypass surgery.

Stigma can also have an effect on a person’s self (Conner et al., 2010; Corrigan et al., 2005; Corrigan, Rafacz, & Rüsch, 2011).  This can occur in no fewer than two different aspects of life.  The first is through the social aspect wherein the mentally ill individual, for the fear of social rejection, tends to limit his/her social networks which may trigger separation, redundancy, reduced income, and as so on.  Findings by Angermeyer, Beck, Dietrich, and Holzinger (2004) add a huge weight to this.  They interviewed a sample of 210 inpatients with schizophrenia or an episode of depression, one half living in a small town and the other in the city.  They found that the majority of the patients did anticipate negative reactions or hostile attitudes from their environment, especially in the areas of access to work and social life.  The sphere of interpersonal interaction was most frequently mentioned in connection with stigmatization experiences.  While schizophrenic patients and those with depression both expected stigmatization likewise often, the former recounted experiences of concrete stigmatization more often than the latter.  Contrariwise, patients who were resident in a small town expected stigmatization more regularly than their counterparts from the city, even as both had truly faced stigmatization at almost the same rate.

Rural Women’s Perception of Mental Health:

The perceptions of African American women, living in rural Georgia, in relationship to mental health seeking processes and service experiences for their adolescents with emotional or behavioral problems were examined.  One of the purposes of this study was to address the gap in research regarding mental health seeking behaviors on African American families living in rural areas (Murry, Heflinger, Suiter, & Brody, 2011).  The examination was part of a longitudinal study that had commenced as far back as 1993 with rural African American families headed by single mothers, officially entitled, “The Families In It Together (FIIT) Project,’ (Murry et al., 2011).  The FIIT project was initiated in reaction to National Institute on Child Health and Development’s special call proposals for “normative developmental processes among ethnic minority children” (NIMH).

The multi-level conceptual model of health services was used to guide the study.   It portrays the patterns of service use that includes help-seeking, as affected by need, predisposing factors, and enabling factors, which are comprised of a family’s knowledge of resources and beliefs about seeking help (Murry et al., 2011).   A mixed-methods approach was used for data collection, and 163 individuals participated in the study. Ninety-three percent of the participants trusted the mental health professionals in their communities and were confident those professionals could help their children; 87 per cent perceived their access to mental health services was adequate; 94% expected some social support when they seek help; and 95% were not embarrassed about seeking help.  Fifty percent of the women also endorsed stigma as a barrier, and were concerned that they would be blamed for their children’s emotional or behavioral problems if people in the community found out their children were receiving help from professionals (Murry et al., 2011).  Their concern about the community’s reaction was also endorsed as a barrier to help-seeking behavior (Murry et al., 2011).  This finding was consistent with the findings in Earlise C Ward and Heidrich (2009) study of African American women who also believed that stigma towards mental illness because of negative cultural perceptions and embarrassment served as barriers for African Americans willingness to seek mental health services.  These findings provide additional information about the perceptions of African American women regarding stigma towards mental illness and help-seeking behavior. Moreover, it provided some information about treatment related activities of African American women in their roles as mothers.

The level of understanding about treatment related activities of African Americans was expanded through a prospective study designed to examine the relationship between stigma and the use of mental health services.  An exploration of the participants’ perception that society stigmatizes mental illness, concerns about stigma for receiving treatment, perceived need for treatment, and treatment concerns were factors included in the study (Alvidrez, Snowden, & Patel, 2010).  The study site was an out-patient mental health clinic located in a county hospital where a pilot study was conducted to examine treatment entry and participation of African American adults.  A comparison was made between participants who were given ethnic specific education materials related to mental health stigma and treatment barriers; and those who were given more general materials about available services (Alvidrez et al., 2010).  Concerns about stigma were related with the severity of mental health symptoms and the perceived need for mental health treatment.  Furthermore, there was a positive association between psychotherapy concerns and doubts about treatment, and stigma concerns (Alvidrez et al., 2010). There was an association between gender and education, and the perception of stigma about mental illness. The men and individuals with a higher level of education demonstrated a higher level of stigma (Alvidrez et al., 2010).

Again, there is inconsistency in the results of E. C. Ward and Besson (2012) study African American men.  However, the participants in this study were drawn from people who went to the clinic for initial intake appointments; it did not include people who may not have complied with a referral to the clinic because of stigma concerns.  Therefore, the sample may have been comprised of people with less concern about stigma than those in the general population (Alvidrez et al., 2010).

Future Scope and Practices:



  • Summary:
  • This chapter summarizes relevant background information related to Stigma, including the frequency of mental disorders in this study. In order to exhibit the urgency of this study, this chapter demonstrated the importance of location and setting and its relevance to prevention and regulation.

The chapter commenced with a general overview of the prevalence of Stigma drawn from the general literature and summarized the evidence relating to Stigma in the United States and the extent to which particular types of mental disorders are known to cause Stigma.  The evidence relating to the role of location and setting in the Stigma conditions is reviewed, and an overview of current guidance is presented.  Following this, a review of literature related to the theoretical framework of the study is presented.  Finally, knowledge gaps about the incidence and causes of Stigma in the United States are highlighted and published recommendations for improving this situation are summarized.



Abu-Ras, W. M., & Suarez, Z. E. (2009). Muslim Men and Women’s Perception of Discrimination, Hate Crimes, and PTSD Symptoms Post 9/11. Traumatology, 15(3), 48–63. doi:10.1177/1534765609342281

Acheson, D. W. (2001). Current trends in foodborne diseases. Medscape Infectious Diseases, 3(2). Retrieved from

Ackerman, J. (2011). Food–How safe? National Geographic Magazine. Retrieved from

Africa Department of Public Health. (2008). 2008 Africa data summary. Retrieved from

Alvidrez, J., Snowden, L. R., & Patel, S. G. (2010). The Relationship between Stigma and Other Treatment Concerns and Subsequent Treatment Engagement among Black Mental Health Clients. Issues in Mental Health Nursing, 31(4), 257–264. Retrieved from

Andrade, L., Berglund, P., Bijl, R., Kessler, R., Demler, O., Walters, E., … Wittchen, H.-U. (2013). Cross-national comparisons of the prevalences and correlates of mental disorders. Bulletin of the World Health Organization. WHO International Consortium in Psychiatric Epidemiology. Retrieved from

Andrews, D. A., & Bonta, J. (2010). Rehabilitating criminal justice policy and practice. Psychology, Public Policy, and Law, 16(1), 39–55. doi:10.1037/a0018362

Angermeyer, M. C., Beck, M., Dietrich, S., & Holzinger, A. (2004). The Stigma of Mental Illness: Patients’ Anticipations and Experiences. International Journal of Social Psychiatry, 50(2), 153–162. doi:10.1177/0020764004043115

Angulo, F. Voetsch.A., Vugia, D., Hadler, J., Farley, M., Hedberg, C., et al. (1998). Determining the burden of human illness from foodborne diseases: CDC’s emerging infectious disease program Foodborne Disease Active Surveillance Network (FoodNet). Veterinary Clinics of North America: Food Animal Practice, 14, 165-172.

APA. (n.d.). Fact and information sheet about: American Psychological Association lesbian, gay, and bisexual concerns policy statements. Fact and Information Sheet. Retrieved August 16, 2013, from Policy Statements Fact Sheet.pdf

Batz, M. B., Doyle, M. P., Morris, Jr., J. G., Painter J., Singh, R.,Tauxe, R.V., et al. (2005). Attributing illness to food. Emerging Infectious Diseases, 11 (7), 993-995.Retrieved from

Baynton, D. C. (2013). Disability and the Justification of Inequality in American History. In L. J. Davis (Ed.), The Disability Studies Reader (4th ed., Vol. 2, pp. 17–33). New York: Routledge. Retrieved from

Belcher, L. M. (2011).  Africa state laws on food vending on streets. Retrieved from

Bell, J. S., Aaltonen, S. E., Airaksinen, M. S., Volmer, D., Gharat, M. S., Muceniece, R., … Chen, T. F. (2010). Determinants of mental health stigma among pharmacy students in Australia, Belgium, Estonia, Finland, India and Latvia. The International journal of social psychiatry, 56(1), 3–14. doi:10.1177/0020764008097621

Bleich, S. N., Jarlenski, M. P., Bell, C. N., & LaVeist, T. A. (2012). Health inequalities: trends, progress, and policy. Annual review of public health, 33, 7–40. doi:10.1146/annurev-publhealth-031811-124658

Bloom, M., & Gullotta, T. P. (2003). Evolving definitions of primary prevention. In T. P. Gullotta & M. Bloom, Eds., Encyclopedia of primary prevention and health promotion (pp. 9-15). New York: Springer.

Boyce, J., Broz, C., & Binkley, M. (2008). Consumer perspectives: Take-out packaging and food safety. British Food Journal, 110(8), 819-828. doiHYPERLINK “”: 10.1108HYPERLINK “″/00070700810893340

Boyd, J. E., Katz, E. P., Link, B. G., & Phelan, J. C. (2010). The relationship of multiple aspects of stigma and personal contact with someone hospitalized for mental illness, in a nationally representative sample. Social Psychiatry and Psychiatric Epidemiology, 45(11), 1063–70. doi:10.1007/s00127-009-0147-9

Broady, A. S. (2010, September 25). New food handling code limits festivals in Savannah. Savannah Morning News: Savannah Now. Retrieved from

Brohan, E., Elgie, R., Sartorius, N., & Thornicroft, G. (2010). Self-stigma, empowerment and perceived discrimination among people with schizophrenia in 14 European countries: The GAMIAN-Europe study. Schizophrenia Research, 122(1), 232–238. Retrieved from

Brohan, E., Slade, M., Clement, S., & Thornicroft, G. (2010). Experiences of mental illness stigma, prejudice and discrimination: a review of measures. BMC health services research, 10(1), 80. doi:10.1186/1472-6963-10-80

Brouwer, M. C., van de Beek, D., Heckenberg, S. B., Spanjaard, L., & de Gans, J. (2006).Community-acquired Listeria monocytogenes meningitis in adults. Clinical Infectious Diseases, 43(10), 1233-1238.

California State University Long Beach (CSULB). (2010). Basis of Stigma. Retrieved from

Card, J., Jonaitis, T., Tafazoli, S., & Magnuson, B. (2011). An appraisal of the published literature on the safety and toxicity of food-related nonmaterial. Critical Reviews In Toxicology, 41(1), 22-49.

Center for Disease Control and Prevention (CDC). (2011). CDC Estimates of Stigma in the United States. Retrieved from www.cdc.gove/foodborneburden/2011

Center for Disease Control and Prevention (CDC). (2012). Food safety at fairs and festivals. Retrieved from Foodborne_Illness_Peaks_in_Summer/index.asp

Center for Infectious Disease Research and Policy (CIDRAP). (2009). Salmonellosis. Retrieved from

Centers for Disease Control and Prevention (2006b).Importance of culture confirmation of Shiga toxin-producing Escherichia coli infection as illustrated by outbreaks of gastroenteritis—New York and North Carolina, 2005.Morbidity and Mortality Weekly Report, 55(38), 1042-1045. Retrieved from

Centers for Disease Control and Prevention (CDC) (2001). “Norwalk-like viruses”: Public health consequences and outbreak management. Morbidity and Mortality Weekly Report, 50(RR09), 1-18. Retrieved from

Centers for Disease Control and Prevention (CDC). (2006a). Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food: 10 states, 2007. Morbidity & Mortality Weekly, 55(14), 366-370.  Retrieved from

Centers for Disease Control and Prevention (CDC). (2010). Food safety at fairs and festivals. Retrieved from

Chatterjee, N. K., Moore, D. W., Monroe, S. S., Glass, R. I., Cambridge, M. J., Kondracki, S., & Morse, D. (2004). Molecular Epidemiology of Outbreaks of Viral Gastroenteritis in New York State, 1998-1999.Clinical Infectious Diseases, 38S303-S310.

Cima, G. (2009). Stigma levels off in past several years. Journal Of The American Veterinary Medical Association, 235(2), 134-136.

Conner, K. O., Copeland, V. C., Grote, N. K., Rosen, D., Albert, S., McMurray, M. L., … Koeske, G. (2010). Barriers to treatment and culturally endorsed coping strategies among depressed African-American older adults. Aging & mental health, 14(8), 971–83. doi:10.1080/13607863.2010.501061

Corrigan, P. W., Kerr, A., & Knudsen, L. (2005). The stigma of mental illness: Explanatory models and methods for change. Applied and Preventive Psychology, 11(3), 179–190. Retrieved from

Corrigan, P. W., Rafacz, J., & Rüsch, N. (2011). Examining a progressive model of self-stigma and its impact on people with serious mental illness. Psychiatry Research, 189(3), 339–343. Retrieved from

Craun, G. F., Calderon, R. L., & Craun, M. F. (2005).Outbreaks associated with recreational water in the United States. International Journal of Environmental Health Research, 15(4), 243-262. doi:10.1080/09603120500155716

Crawford, L. C., Crawford, M. L., & Moore, S. R. (2010).Hemolytic-uremic syndrome in a grandmother. Emerging Infectious Diseases, 16(11), 1792-1795. doi:10.3201/eid1611091464

Creswell, J. W. (2008). Research design: Qualitative, quantitative, and mixed-method approaches (3rd ed.). Thousand Oaks, CA: Sage.

Daradkeh, T. K., Eapen, V., & Ghubash, R. (2005). Mental Morbidity in Primary Care in Al Ain (UAE): Application of the Arabic Translation of the PRIME- MD (PHQ) Version. German Journal of Psychiatry, 8(3), 32–35.

De Jong, A., Verhoeff-Bakkenes, L., Nauta, M., & de Jonge, R. (2008). Cross-contamination in the kitchen: Effect of hygiene measures. Journal Of Applied Microbiology, 105(2), 615-624.

De Jonge, J., Van Trijp, H., Renes, R., & Frewer, L. (2010). Consumer confidence in the safety of food and newspaper coverage of food safety issues: A longitudinal perspective. Risk Analysis: An Official Publication Of The Society For Risk Analysis, 30(1), 125-142.

Delea K.C., Selman C.A., & EHS-Net. (2008). Understanding foodborne disease outbreaks using environmental assessment. Presented at the Conference on Emerging Infectious Diseases Biannual Meeting; 2008 March 16-19, Atlanta.

Delea, K. (2012). Evaluating local and state food and water safety programs. Journal Of Environmental Health, 74(7), 32-33.

DeWaal, C. S. (2006). Underreporting of Stigma: Strategies to increase awareness and diagnosis. Presentation to the Food Safety Education Conference, Denver, Colorado, September 27-29, 2006. Retrieved from

DeWaal, C. S. (2010). Beyond attribution: State-by-state outbreak reporting. Presentation to Food Safety Education Conference, Atlanta, Africa, March 23-26, 2010. Retrieved from

Druss, B. G., Bradford, D. W., Rosenheck, R. A., Radford, M. J., & Krumholz, H. M. (2000). Mental Disorders and Use of Cardiovascular Procedures After Myocardial Infarction. JAMA, 283(4), 506. doi:10.1001/jama.283.4.506

Eapen, V., & El-Rufaie, O. (2008). United Arab Emirates (UAE). International Psychiatry, 5(2), 38–40.

Evans-Lacko, S., Brohan, E., Mojtabai, R., & Thornicroft, G. (2012). Association between public views of mental illness and self-stigma among individuals with mental illness in 14 European countries. Psychological medicine, 42(8), 1741–52. doi:10.1017/S0033291711002558

Faul, F., Edgar, E & Lang., A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39 (2), 175-191.

Figueira, T. R., Ferreira e Ferreira, E., Schall, V. T., &Modena, C. M. (2009). Women’s perceptions and practices regarding prevention and health promotion in primary healthcare. Revista de SaúdePública, 43(6). doi: 10.1590/S0034-89102009005000081

Food and Drug Administration. (2009). Food Code. U.S. College Park, MD: Department of Health and Human Services. Retrieved from

Food-borne illness [Editorial]. (2006, November 22). Naples Daily News. Retrieved from

Freudenberg, N., Daniels, J., Crum, M., Perkins, T., & Richie, B. E. (2008). Coming Home From Jail: The Social and Health Consequences of Community Reentry for Women, Male Adolescents, and Their Families and Communities. Am J Public Health, 98(Supplement_1), S191–S202. doi:10.2105/AJPH.98.Supplement_1.S191

Friis, Robert. (2009). Introduction to Public Health Practice. Jones & Bartlett Learning Volume (1) ISBN: 14449613616.

Ghubash, R., El-Rufaie, O., Zoubeidi, T., Al-Shboul, Q. M., & Sabri, S. M. (2004). Profile of mental disorders among the elderly United Arab Emirates population: sociodemographic correlates. International Journal of Geriatric Psychiatry, 19(4), 344–51. doi:10.1002/gps.1101

Goffman, E. (2009). Stigma: Notes on the Management of Spoiled Identity (Google eBook) (Vol. 2009, p. 168). New York: Simon and Schuster. Retrieved from

Govender, V., & Penn-Kekana, L. (2008). Gender biases and discrimination: a review of health care interpersonal interactions. Global public health, 3 Suppl 1(June), 90–103. doi:10.1080/17441690801892208

Govender, V., & Penn-Kekana, L. (2009). Challenging Gender in Patient-Provider Interactions. In G. Sen & P. Östlin (Eds.), Gender Equity in Health: The Shifting Frontiers of Evidence and Action (Google eBook) (pp. 184–209). e-Library: Taylor & Francis. Retrieved from

Green, K. Y., Belliot, G., Taylor, J., Valdesuso, J., Lew, J. F., Kapikian, A. Z., & Lin, F. C. (2002). A predominant role for norwalk-like viruses as agents of epidemic gastroenteritis in <Maryland nursing homes for the elderly. Journal Of Infectious Diseases, 185(2), 133.

Hamdan, A. (2009). Mental health needs of Arab women. Health care for women international, 30(7), 595–613. doi:10.1080/07399330902928808

Hampton, N. Z., & Sharp, S. E. (2013). Shame-Focused Attitudes Toward Mental Health Problems: The Role of Gender and Culture. Rehabilitation Counseling Bulletin, 0034355213501722–. doi:10.1177/0034355213501722

Hargrove, T. (2006).A Russian roulette of food poisoning in American states. Scripps Howard News Service.  Retrieved from

Hatzenbuehler, M. L., McLaughlin, K. A., Keyes, K. M., & Hasin, D. S. (2010). The impact of institutional discrimination on psychiatric disorders in lesbian, gay, and bisexual populations: a prospective study. American journal of public health, 100(3), 452–9. doi:10.2105/AJPH.2009.168815

Henderson, J., Coveney, J., & Ward, P. (2010). Who regulates food? Australians’ perceptions of responsibility for food safety. Australian Journal Of Primary Health, 16(4), 344-351.

Hitchins, A. D., & Whiting, R. C. (2001). Food-borne Listeria monocytogenes risk assessment. Food Additives & Contaminants, 18(12), 1108-1117. doi:10.1080/02652030110050104

Hoffman, R.E., Greenblatt, J., Matyas, B.T., Sharp, D.J., Esteban, E., Hodge, K., & Liang, A. (2005). Capacity of state and territorial health agencies to prevent Stigma. Emerging Infectious Diseases, 11(1), 11-6.Retrieved from

Hoffmann, S. (2009). Knowing which foods are making us sick. Choices 24(2). Retrieved from

Howell’s D. (2010).Fundamental statistics for the behavioral sciences. Wadsworth Publishing; 7th edition. ISBN: 0495811254

Hunter, L. R., & Schmidt, N. B. (2010). Anxiety psychopathology in African American adults: Literature review and development of an empirically informed sociocultural model. Psychological Bulletin, 132(2), 211–235. doi:10.1037/a0018133

Ivanov, L. L., & Blue, C. L. (2008).Public health nursing: Leadership, policy, & practice. Clifton Park, NY: Delmar Cen Learning.

Jablensky, A., & Kendell, R. E. (2002). Criteria for Assessing a Classification in Psychiatry. In M. Maj, W. Gaebel, J. J. López-Ibor, & N. Sartorius (Eds.), Psychiatric Diagnosis and Classification (p. 299). Chichester, UK: John Wiley & Sons, Ltd. doi:10.1002/047084647X

Jacob, C., Mathiasen, L., & Powell, D. (2010).Designing effective messages for microbial food safety hazards. Food Control, 21(1), 1-6. doi:10.1016/j.foodcont.2009.04.011

Jaspal, R., & Cinnirella, M. (2010). Coping with potentially incompatible identities: accounts of religious, ethnic, and sexual identities from British Pakistani men who identify as Muslim and gay. The British journal of social psychology / the British Psychological Society, 49(Pt 4), 849–70. doi:10.1348/014466609X485025

Jaspal, R., & Siraj, A. (2011). Perceptions of “coming out” among British Muslim gay men. Psychology and Sexuality, 2(3), 183–197. doi:10.1080/19419899.2010.526627

Jones, T. F., Pavlin, B.I., LaFleur, B.J., Ingram,L.A., &Schaffner, W. (2004). Restaurant inspection scores and foodborne disease. Emerging Infectious Diseases, 10(4), 688-92.Retrieved from

Jones, T.F., & Gerber, D.E. (2001).Perceived etiology of Stigma among public health personnel. Emerging Infectious Diseases, 7(5), 904-5.Retrieved from

Kaye, K. E. (2012, September 11). Public stigma toward housing applicants with psychiatric disabilities. San Diego State University. Retrieved from

Kronfol, N. M. (2012). Health services to groups with special needs in the Arab world: a review. Eastern Mediterranean Health Journal, 18(12), 1247–53. Retrieved from

Laird, L. D., Amer, M. M., Barnett, E. D., & Barnes, L. L. (2007). Muslim patients and health disparities in the UK and the US. Arch Dis Child, 92(10), 922–6. doi:10.1136/adc.2006.104364

Lasalvia, A., & Tansella, M. (2008). Fighting discrimination and stigma against people with mental disorders. Epidemiologia e Psichiatria Sociale, 17(01), 1–9. doi:10.1017/S1121189X00002608

Lawton, J., & Schulte, S. J. (2012). The prevalence of mental health symptoms among outpatients in the United Arab Emirates. The Arab Journal of Psychiatry, 23(2), 138–147.

Leavell, H.R., & Clark, E.G. (1965). Preventive medicine for the doctor in his community: An epidemiologic approach (3rded.). New York: McGraw-Hill.

Levin, J., Chatters, L. M., & Taylor, R. J. (2005). Religion, health and medicine in African Americans: implications for physicians. Journal of the National Medical Association, 97(2), 237–49. Retrieved from

Li, M., Muthaiyan, A., O’Bryan, C., Gustafson, J., Li, Y., Crandall, P., &Ricke, S. (2011). Use of natural antimicrobials from a food safety perspective for control of Staphylococcus aureus. Current Pharmaceutical Biotechnology, 12(8), 1240-1254.Lund, B., & O’Brien, S. (2011). The occurrence and prevention of foodborne disease in vulnerable people. Foodborne Pathogens And Disease, 8(9), 961-973.

Lindsey, M. A., Joe, S., & Nebbitt, V. (2010). Family Matters: The Role of Mental Health Stigma and Social Support on Depressive Symptoms and Subsequent Help Seeking Among African American Boys. The Journal of black psychology, 36(4), 458–482. doi:10.1177/0095798409355796

Livingston, J. D., & Boyd, J. E. (2010). Correlates and consequences of internalized stigma for people living with mental illness: A systematic review and meta-analysis. Social Science & Medicine, 71(12), 2150–2161. Retrieved from

Lupien, J. (2007). Prevention and control of food safety risks: The role of governments, food producers, marketers, and academia. Asia Pacific Journal of Clinical Nutrition, 16(Suppl 1), 74-79.

MacDonald, P. M., Whitwam, R. E., Boqqs, J. D., Newton McCormack, J. J., Anderson, K. L., Reardon, J. W., & … Sobel, J. (2005). Outbreak of listeriosis among Mexican immigrants as a result of consumption of illicitly produced Mexican-style cheese. Clinical Infectious Diseases, 40(5), 677-682.

Malmusi, D., Borrell, C., & Benach, J. (2010). Migration-related health inequalities: Showing the complex interactions between gender, social class and place of origin. Social Science & Medicine, 71(9), 1610–1619. Retrieved from

Markowitz, F. E. (2011). Mental illness, crime, and violence: Risk, context, and social control. Aggression and Violent Behavior, 16(1), 36–44. Retrieved from

Marler, W.D. (2007).Tracking Stigma: a lawyer’s viewpoint. Australian Journal of Dairy Technology, 62(2), 49-54.

Martínez y Martínez, R., &Martínez-Carboney, R. (1997). [The Wiedemann-Beckwith syndrome. Its natural history and levels of prevention].GacetaMédica De México, 133(3), 195-202.

Matyas, B., Cronquist, A., Carter, M., Tobin-D’Angelo, M., Blythe, D., Smith, K, &Tauxe, R.V. (2010).Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food: 10 states, 2009. Morbidity & Mortality Weekly Report, 59(14), 418-422. Retrieved from

McAndrew, L. M., Musumeci-Szabó, T. J., Mora, P. A., Vileikyte, L., Burns, E., Halm, E. A., … Leventhal, H. (2008). Using the common sense model to design interventions for the prevention and management of chronic illness threats: from description to process. British Journal of Health Psychology, 13(Pt 2), 195–204. doi:10.1348/135910708X295604

McEwen, M. (2002). Community-based nursing: An introduction. New York: Elsevier Health Sciences.

Mead, P.S., Slutsker, L., Dietz, V., McCaig, L.F., Bresee, J.S., Shapiro, C. … &Tauxe, R.V. (1999). Food-related illness and death in the United States. Emerging Infectious Diseases, 5(5), 607-625.Retrieved from

Melkonyan, T.A., & Schubert, J. (2009). Food regulations under ambiguity. American Journal of Agricultural Economics, 91(5), 1389–1396. doi:10.1111/j.1467-8276.2009.01353.x

Mitchell, R., Fraser, A., & Bearon, L. (2007). Preventing food-borne illness in food service establishments: Broadening the framework for intervention and research on safe food handling behaviors. International Journal Of Environmental Health Research, 17(1), 9-24.

Mobile food unit standard Thomas Jefferson health district. (2003). Retrieved from “”&HYPERLINK “”hl=enHYPERLINK “”&HYPERLINK “”ion=1HYPERLINK “”&HYPERLINK “”qscrl=1HYPERLINK “”&HYPERLINK “”rlz=1T4AURU_enUS499US500#hl=enHYPERLINK “”&HYPERLINK “”suge

Moe, C., Christmas, W., Echols, L., & Miller, S. (2001). Outbreaks of acute gastroenteritis associated with Norwalk-like viruses in campus settings. Journal of American College Health, 50(2), 57-66.

Morabito, M. S., Kerr, A. N., Watson, A., Draine, J., Ottati, V., & Angell, B. (2010). Crisis Intervention Teams and People With Mental Illness: Exploring the Factors That Influence the Use of Force. Crime & Delinquency, 58(1), 57–77. doi:10.1177/0011128710372456

Murry, V. M., Heflinger, C. A., Suiter, S. V, & Brody, G. H. (2011). Examining perceptions about mental health care and help-seeking among rural African American families of adolescents. Journal of youth and adolescence, 40(9), 1118–31. doi:10.1007/s10964-010-9627-1

Neighbors, H. W., Caldwell, C., Williams, D. R., Nesse, R., Taylor, R. J., Bullard, K. M., … Jackson, J. S. (2007). Race, ethnicity, and the use of services for mental disorders: results from the National Survey of American Life. Archives of general psychiatry, 64(4), 485–94. doi:10.1001/archpsyc.64.4.485

Nyambok, E., & Kastner, J. (2012). United States import safety, environmental health, and food safety regulation in China. Journal Of Environmental Health, 74(6), 28-34.

Olsen, R.K., Eidson, M., & Sewell, C.M. (1997).Staphylococcal food poisoning from a fundraiser. Journal of Environmental Health, 60(3), 7-11.

Olsen, S. J., MacKinnon, L. C., Goulding, J. S., Bean, N. H., & Slutsker, L. (2000). Surveillance for foodborne-disease outbreaks: United States, 1993-1997. Morbidity and Mortality Weekly Report, 49(SS-1), 1-51.Patten, M. L. (2002).Understanding research methods: An Overview of the essentials (3rd ed.). Los Angeles: Pyrczak Publishing.

Pepins, L. A., Highfill, K. A., Barrett, E., Monti, M. M., Hackler, R., Huang, P., & Jiang, X. (2002).A Norwalk-like virus outbreak on the Appalachian Trail. Journal of Environmental Health, 64(9), 18.

Pham, M., Jones, A., Dewey, C., Sargeant, J., & Marshall, B. (2012). Food safety issues and information needs: An online survey of public health inspectors. Journal Of Environmental Health, 74(10), 22-29.

Phelan, J. C., Link, B. G., Stueve, A., Pescosolido, B. A., Health, J., Behavior, S., … Phelan, J. O. C. (2000). Public Conceptions of Mental Illness in 1950 and 1996 : What Is Mental Illness and Is It to be Feared ? ournal of Health and Social Behavior, 41(2), 188–207.

Pieterse, A. L., Todd, N. R., Neville, H. a, & Carter, R. T. (2012). Perceived racism and mental health among Black American adults: a meta-analytic review. Journal of Counseling Psychology, 59(1), 1–9. doi:10.1037/a0026208

Rangel, J. M., Sparling, P. H., Crowe, C., Griffin, P. M., & Swerdlow, D. L. (2005).Epidemiology of Escherichia coliO157:H7 outbreaks, United States, 1982–2002. Emerging Infectious Diseases, 11, 603-609.Retrieved from

Ridgeway, C. L. (2012). Framed by Gender: How Gender Inequality Persists in the Modern World. Social Forces, 92(1), 401–405. doi:10.1093/sf/sos157

Samuel, M. C., Vugia, D. J., Shallow, S., Marcus, R., Segler, S., McGivern, T., & … Tauxe, R. V. (2004).Epidemiology of sporadic Campylobacter infection in the United States and declining trend in incidence, FoodNet 1996–1999.Clinical Infectious Diseases, 38, S165-S174.

Saxena, S., Thornicroft, G., Knapp, M., & Whiteford, H. (2007). Resources for mental health: scarcity, inequity, and inefficiency. The Lancet, 370(9590), 878–89. doi:10.1016/S0140-6736(07)61239-2

Scallan, E., Hoekstra, R. M., Angulo, F. J., Tauxe, R. V., Widdowson, M., Roy, S. L., & … Griffin, P. M. (2011).Stigma acquired in the United States–major pathogens. Emerging Infectious Diseases, 17(1), 7-15. doi:10.3201/eid1701.P11101

Schmutz, P. H. (2010). Food-borne illness: prevention strategies. Clemson Cooperative      Extension: Clemson University. Retrieved from

Schoen, C., Osborn, R., How, S. K. H., Doty, M. M., & Peugh, J. (2009). In chronic condition: experiences of patients with complex health care needs, in eight countries, 2008. Health affairs (Project Hope), 28(1), w1–16. doi:10.1377/hlthaff.28.1.w1

Schwartz, S., & Meyer, I. H. (2010). Mental health disparities research: the impact of within and between group analyses on tests of social stress hypotheses. Social Science & Medicine, 70(8), 1111–8. doi:10.1016/j.socscimed.2009.11.032

Sellers, S., Cherepanav, D., Hanmer, J., Fryback, D. G., & Palta, M. (2013). Interpersonal discrimination and health-related quality of life among black and white men and women in the United States. Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation, 22(6), 1307–12. doi:10.1007/s11136-012-0258-8

Sharma, V. K., Lepping, P., Krishna, M., Durrani, S., Copeland, J. R. M., Mottram, P., … Cummins, A. (2008). Mental health diagnosis by nurses using the Global Mental Health Assessment Tool: a validity and feasibility study. Br J Gen Pract., 58(551), 411–6. doi:10.3399/bjgp08X299218

Shives, L. R. (2008). Basic Concepts of Psychiatric-mental Health Nursing (7th ed., p. 749). Philadelphia: Lippincott Williams & Wilkins. Retrieved from

Silverstone, P. H., Krameddine, Y. I., DeMarco, D., & Hassel, R. (2013). A Novel Approach to Training Police Officers to Interact With Individuals Who May Have a Psychiatric Disorder. J Am Acad Psychiatry Law, 41(3), 344–355. Retrieved from

Smith, D., Novotnaj, K., & Smith, G. (2010).Preharvest food safety: What do the past and the present tell us about the future?  Journal Of Agromedicine, 15(3), 275-280.

Snowden, L. R. (2012). Health and mental health policies’ role in better understanding and closing African American–White American disparities in treatment access and quality of care. American Psychologist, 67(7), 524–531. doi:10.1037/a0030054

Spencer, R., & Chesler, P. (2007). The violent oppression of women in Islam (p. 31). Los Angeles: David Horowitz Freedom Center.

Steadman, H. J., McCarty, D. W., & Morrissey, J. P. (1989). The Mentally Ill in Jail: Planning for Essential Services (p. 242). New York: Guilford Press. Retrieved from

Sternberg, J., & Sulka, A. (2010). Food safety and restaurant inspection. Retrieved from

Tester, J.M., Stevens, S.A., Yen, I.H., & Laraia, B.A. (2010).An analysis of public health policy and legal issues relevant to mobile food vending. American Journal of Public Health, 100(11), 2038-2046. doi:10.2105/AJPH.2009.185892

Thorne, A. (2013). Facial stigmata and their powerful effects in literature and life. JAMA dermatology (Chicago, Ill.), 149(5), 569. doi:10.1001/jamadermatol.2013.2984

Thornicroft, G. (2008). Stigma and discrimination limit access to mental health care. Epidemiologia e Psichiatria Sociale, 17(1), 14–9. Retrieved from

Thornicroft, G., Brohan, E., Rose, D., Sartorius, N., & Leese, M. (2009). Global pattern of experienced and anticipated discrimination against people with schizophrenia: a cross-sectional survey. The Lancet, 373(9661), 408–415. Retrieved from

Thornicroft, G., Rose, D., & Kassam, A. (2007). Discrimination in health care against people with mental illness. International Review of Psychiatry, 19(2), 113–22. doi:10.1080/09540260701278937

United States Department of Agriculture. (2011).Stigma peaks in summer – Why? Retrieved from

United States Department of Agriculture. (2012). Seasonal food safety. Retrieved from

Vázquez-Barquero, J. L., Diez Manrique, J. F., Muñoz, J., Menendez Arango, J. M., Gaite, L., Herrera, S., & Der, G. J. (1992). Sex differences in mental illness: a community study of the influence of physical health and sociodemographic factors. Social psychiatry and psychiatric epidemiology, 27(2), 62–8. Retrieved from

Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007). Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes toward counseling. Journal of Counseling Psychology, 54(1), 40–50. doi:10.1037/0022-0167.54.1.40

Vugia, D., Cronquist, A., Cartter, M., Tobin-D’Angelo, M., Blythe, D., Smith, K. …. &Trivedi, K.K. (2008). Preliminary FoodNet data on the incidence of infection with pathogens transmitted commonly through food: 10 states. Morbidity & Mortality Weekly Report, 58 (14), 366-370. Retrieved from

Waldron, I. (2010). marginalization of African indigenous healing traditions within western medicine: reconciling ideological tensions & contradictions along the epistemological terrain. Women’s Health and Urban Life, 9(1), 50–68. Retrieved from

Ward, E. C., & Besson, D. D. (2012). African American Men’s Beliefs About Mental Illness, Perceptions of Stigma, and Help-Seeking Barriers. The Counseling Psychologist, 41(3), 359–391. doi:10.1177/0011000012447824

Ward, Earlise C, & Heidrich, S. M. (2009). African American women’s beliefs about mental illness, stigma, and preferred coping behaviors. Research in nursing & health, 32(5), 480–92. doi:10.1002/nur.20344

Watanabe, S., Melby, M., & Aiba, N. (2009).Food safety and food labeling from the viewpoint of the consumers. Asia Pacific Journal Of Clinical Nutrition, 18(4), 532-537.

Werner, P., Mittelman, M. S., Goldstein, D., & Heinik, J. (2012). Family stigma and caregiver burden in Alzheimer’s disease. The Gerontologist, 52(1), 89–97. doi:10.1093/geront/gnr117

Wickham, L., Yee, K., & George, L. (2007).Preparing to Receive the Crumbine Award. Journal Of Environmental Health, 69(9), 72-75.

Wikswo M. E. and Hall, A. J.  (2012). Outbreaks of acute gastroenteritis transmitted by person to person contact- United States, 2009-2010.  Surveillance Summaries, 61(SS09), 1-12

Williams, C. L. (1995). Still a Man’s World: Men who Do “women’s Work” (p. 243). Berkeley andLos Angeles: University of California Press. Retrieved from

Winquist, A. G., Roome, A., Mshar, R., Fiorentino, T., Mshar, P., & Hadler, J. (2001).Outbreak of campylobacteriosis at a senior center. Journal of the American Geriatrics Society, 49(3), 304-307. doi:10.1046/j.1532-5415.2001.4930304.x

Wong, S., Marcus, R., Hawkins, M., Shallow, S., Mccombs, K. G., Swanson, E., Gilder, T. (2004). Physicians as Food-Safety Educators: A Practices and Perceptions Survey. Clinical Infectious Diseases, 38S212-S218.

Yarrow, L., Remig, V., & Higgins, M. (2009). Food safety educational intervention positively influences college students’ food safety attitudes, beliefs, knowledge, and self-reported practices. Journal Of Environmental Health, 71(6), 30-35.

Yasuda, T. (2010). Food safety regulation in the United States: An empirical and theoretical examination. The Independent Review, 15(2), 201-225.

York, VK., Brannon, LA., Shanklin, CW., Roberts, KR., Howells, AD., Barrett, EB. (2009). Foodservice employees benefit from interventions targeting barriers to food safety. Journal of American Dietary Association, 109 (9): 1576-81.

Zur, O., & Nordmarken, N. (2013). DSM: Diagnosing for Status and Money- Summary Critique of the DSM-5. Zur Institute Online Course. Retrieved August 17, 2013, from






Proposed research project:



Issue Decision
Researcher access/exit A consent letter is going to be required officially from the Manager of School just before doing the research within the chosen institution.


Information and facts provided to the contributors The contributors are going to be informed properly just before distributing the questionnaires. A simple information

regarding the intention of the study is going to be informed clearly, and described cautiously before the data collection (including interview as well).



Contributors right to withdraw


Participants are going to have the ability to withdraw from the study, whenever they want, without the need of providing any explanation.

This information and facts will be mentioned clearly within the consent form, and definitely will be told to the contributors in advance of any data collection takes place. Any withdrawals is going to be handled professionally, with full respect.


Get Professional Assignment Help Cheaply

Buy Custom Essay

Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?

Whichever your reason is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.

Why Choose Our Academic Writing Service?

  • Plagiarism free papers
  • Timely delivery
  • Any deadline
  • Skilled, Experienced Native English Writers
  • Subject-relevant academic writer
  • Adherence to paper instructions
  • Ability to tackle bulk assignments
  • Reasonable prices
  • 24/7 Customer Support
  • Get superb grades consistently

Online Academic Help With Different Subjects


Students barely have time to read. We got you! Have your literature essay or book review written without having the hassle of reading the book. You can get your literature paper custom-written for you by our literature specialists.


Do you struggle with finance? No need to torture yourself if finance is not your cup of tea. You can order your finance paper from our academic writing service and get 100% original work from competent finance experts.

Computer science

Computer science is a tough subject. Fortunately, our computer science experts are up to the match. No need to stress and have sleepless nights. Our academic writers will tackle all your computer science assignments and deliver them on time. Let us handle all your python, java, ruby, JavaScript, php , C+ assignments!


While psychology may be an interesting subject, you may lack sufficient time to handle your assignments. Don’t despair; by using our academic writing service, you can be assured of perfect grades. Moreover, your grades will be consistent.


Engineering is quite a demanding subject. Students face a lot of pressure and barely have enough time to do what they love to do. Our academic writing service got you covered! Our engineering specialists follow the paper instructions and ensure timely delivery of the paper.


In the nursing course, you may have difficulties with literature reviews, annotated bibliographies, critical essays, and other assignments. Our nursing assignment writers will offer you professional nursing paper help at low prices.


Truth be told, sociology papers can be quite exhausting. Our academic writing service relieves you of fatigue, pressure, and stress. You can relax and have peace of mind as our academic writers handle your sociology assignment.


We take pride in having some of the best business writers in the industry. Our business writers have a lot of experience in the field. They are reliable, and you can be assured of a high-grade paper. They are able to handle business papers of any subject, length, deadline, and difficulty!


We boast of having some of the most experienced statistics experts in the industry. Our statistics experts have diverse skills, expertise, and knowledge to handle any kind of assignment. They have access to all kinds of software to get your assignment done.


Writing a law essay may prove to be an insurmountable obstacle, especially when you need to know the peculiarities of the legislative framework. Take advantage of our top-notch law specialists and get superb grades and 100% satisfaction.

What discipline/subjects do you deal in?

We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.

Are your writers competent enough to handle my paper?

Our essay writers are graduates with bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.

What if I don’t like the paper?

There is a very low likelihood that you won’t like the paper.

Reasons being:

  • When assigning your order, we match the paper’s discipline with the writer’s field/specialization. Since all our writers are graduates, we match the paper’s subject with the field the writer studied. For instance, if it’s a nursing paper, only a nursing graduate and writer will handle it. Furthermore, all our writers have academic writing experience and top-notch research skills.
  • We have a quality assurance that reviews the paper before it gets to you. As such, we ensure that you get a paper that meets the required standard and will most definitely make the grade.

In the event that you don’t like your paper:

  • The writer will revise the paper up to your pleasing. You have unlimited revisions. You simply need to highlight what specifically you don’t like about the paper, and the writer will make the amendments. The paper will be revised until you are satisfied. Revisions are free of charge
  • We will have a different writer write the paper from scratch.
  • Last resort, if the above does not work, we will refund your money.

Will the professor find out I didn’t write the paper myself?

Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.

What if the paper is plagiarized?

We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.

When will I get my paper?

You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.

Will anyone find out that I used your services?

We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.

How our Assignment  Help Service Works

1.      Place an order

You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.

2.      Pay for the order

Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.

3.      Track the progress

You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.

4.      Download the paper

The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.

smile and order essaysmile and order essay PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET A PERFECT SCORE!!!

order custom essay paper