Available online at www.sciencedirect.

com

ScienceDirect
Comprehensive Psychiatry 56 (2015) 198 205
www.elsevier.com/locate/comppsych

Psychometric properties of a Chinese version of the Stigma Scale:

examining the complex experience of stigma and its relationship with
self-esteem and depression among people living with
mental illness in Hong Kong
Andy H.Y. Ho a, b, c , Jordan S. Potash b, d, e , Ted C.T. Fong b , Vania F.L. Ho b , Eric Y.H. Chen f ,
Robert H.W. Lau g , Friendly S.W. Au Yeung h , Rainbow T.H. Ho b, d,
a

Division of Psychology, School of Humanities and Social Sciences, Nanyang Technological University, Singapore
b
Centre on Behavioral Health, The University of Hong Kong, Hong Kong, China
c
Sau Po Centre on Ageing, The University of Hong Kong, Hong Kong, China
d
Department of Social Work and Social Administration, The University of Hong Kong, Hong Kong, China
e
Art Therapy Program, The George WA University, Washington, DC, USA
f
Department of Psychiatry, The University of Hong Kong, Hong Kong, China
g
Lok Hong Intergrated Community Centre for Mental Wellness, Tung Wah Group of Hospital, Hong Kong, China
h
The Providence Garden for Rehab, Hong Kong Sheng Kung Hui Welfare Council, Hong Kong, China

Abstract
Background: Stigma of mental illness is a global public health concern, but there lacks a standardized and cross-culturally validated
instrument for assessing the complex experience of stigma among people living with mental illness (PLMI) in the Chinese context.
Aim: This study examines the psychometric properties of a Chinese version of the Stigma Scale (CSS), and explores the relationships
between stigma, self-esteem and depression.
Methods: A cross-sectional survey was conducted with a community sample of 114 Chinese PLMI in Hong Kong. Participants completed the CSS, the
Chinese Self-Stigma of Mental Illness Scale, the Chinese Rosenberg Self-Esteem Scale, and the Chinese Patient Health Questionnaire-9. An exploratory
factor analysis was conducted to identify the underlying factors of the CSS; concurrent validity assessment was performed via correlation analysis.
Results: The original 28-item three-factor structure of the Stigma Scale was found to be a poor fit to the data, whereas a revised 14-item
three-factor model provided a good fit with all 14 items loaded significantly onto the original factors: discrimination, disclosure and positive
aspects of mental illness. The revised model also displayed moderate to good internal consistency and good construct validity. Further
findings revealed that the total stigma scale score and all three of its subscale scores correlated negatively with self-esteem; but only total
stigma, discrimination and disclosure correlated positively with depression.
Conclusion: The CSS is a short and user-friendly self-administrated questionnaire that proves valuable for understanding the multifaceted
stigma experiences among PLMI as well as their impact on psychiatric recovery and community integration in Chinese communities.
2014 Elsevier Inc. All rights reserved.

1. Introduction
Stigma of mental illness is a global public health concern.
Repeated studies in both Western and Eastern societies have
Corresponding author at: Centre on Behavioral Health, The University
of Hong Kong. 2/F, The HKJC Building for Interdisciplinary Research, 5
Sassoon Road, Pokfulam, Hong Kong, China. Tel.: +852 2831 5169;
fax: +852 2816 6710.
E-mail address: tinho@hku.hk (R.T.H. Ho).
http://dx.doi.org/10.1016/j.comppsych.2014.09.016
0010-440X/ 2014 Elsevier Inc. All rights reserved.

found that people living with mental illness (PLMI),

regardless of their ethnicity and race, are often robbed of
valuable life opportunities such as stable employment, adequate
housing, satisfactory healthcare, and civil engagement as a
result of social stigma [1,2]. Undermined by prejudice and
discrimination, it is also common for PLMI to internalize social
stigma to become increasingly withdrawn and self-isolated,
losing self-esteem and self-efficacy in the process [3]. Both
social stigma and internalized stigma act as major barriers
to medication adherence and psychiatric rehabilitation, which

A.H.Y. Ho et al. / Comprehensive Psychiatry 56 (2015) 198205

in turn create a downward spiral of worsening illness,

posing clear threats to individual and public health [4]. This
is especially true in Chinese communities like Hong Kong
where mental illness has long been a major taboo associated
with matters of family failures.
According to Government statistics, an estimated 14 to
24% of Hong Kong's 7.1 million residents are living with
mental illness, and approximately 70,000 to 200,000 people
suffer from a severe mental disorder [5]. Despite this
astounding figure, only 1% is currently receiving psychiatric
services [6]. The underlying reasons for such gross undertreatment are due not only to traditional taboos, but also the
prominence of collective ideas in Chinese cultures. Having
mental illness within the family is traditionally regarded
as matters of inferior origins, failure of parents, and even
retributions for the sins of past generations [2]. Hence, it
is far too common for Chinese people to feel ashamed of
their mental illness as they are often belittled and looked
down upon, and perceived as dangerous, irresponsible
and untrustworthy [7,8]. The degradation of social and
self-stigma greatly limits the practical and emotional support
they receive because they dare not to speak publicly about
their needs or to seek help within the community for fear of
losing face and disgracing the family name [9]. The burdens
of stigma and isolation are exacerbated through conventional
psychiatric services that are limited to in-patient care and
hospital rehabilitation programs [10], resulting in more
palpable difficulties in community reintegration among
PLMI in the Chinese context. Thus, in order to develop
adequate rehabilitation programs that facilitate both recovery
and inclusion, it is imperative to attain an in-depth understanding on the experience of stigma among Chinese PLMI.
While researchers have long studied public attitudes
towards mental illness, less has been done on assessing the
experience of stigma from the vantage point of PLMI, and
particularly within the Chinese context [11]. This is due
largely in part to the lack of a conceptual agreement over
internalized stigma as well as the limited number of
standardized instruments to measure it. Although recent
literature has provided a more systematic definition of
internalized stigma: a subjective process, embedded within
a socio-cultural context, which may be characterized by
negative feelings (about self), maladaptive behavior, identity
transformation, or stereotypes endorsement resulting from an
individual experiences, perceptions or anticipation of notable
social reactions on the basis of their mental illness' [12]; such
a delineation is still considered by some to be overly negative
and does not capture the full spectrum of experiences.
According to Dinos et al. [13], experiences of stigma among
PLMI are not universally negative, as some individuals may
find that their mental illness enhances their experience of life
and interpersonal relationships. Finlay et al. [14] and others
[15,16] argued that stigma has the potential to arouse a
positive construction of identity as PLMI employ various
strategies to protect and bolster their self-esteem through
inequality and adversity. Shih [17] further contended that

199

individuals living successfully with stigma may adopt

an empowering stance as opposed to a coping stance for
overcoming prejudice and discrimination, gaining strength
and learning valuable life lessons throughout the process;
therefore, in trying to understand how to ward off the
negative consequences of stigma, investigators should also
focus onidentify factors that allow them to achieve this
successful outcome.
Unfortunately, most commonly used standardized instruments that evaluate stigma from the perspectives of PLMI
focus predominately on negative aspects [18], to the extent
that respondents often find them offensive and refuse to
complete them [19]. One instrument recently developed by
King et al. [20] consists of a dimension that taps into the
potential positive aspects of mental illness, which allows for
a more comprehensive assessment over the multifaceted
experience of stigma. The Stigma Scale (SS) was originally
developed from detailed qualitative interviews with 46 PLMI
with regards to their feelings and experiences of prejudice
and discriminations [13], and later validated via 193 service
users in the UK. The initial scale composed of 42 items
that were reduced to 28 items with a three-factor structure
through exploratory factor analysis. The first factor of
discrimination contains 13 statements that concern the
perceived hostility by others or lost opportunity because of
prejudice attitudes; the second factor of disclosure contains
10 statements that concern the need to conceal mental illness
to avoid discrimination; and the third factor of positive
aspects contains 5 statements that concern how people accept
their illness and the potential to become a stronger, more
understanding and accepting person. Each statement is rated
on a 5-point Likert scale, with higher scores indicating
higher levels of perceived stigma. The Stigma Scale has
shown good reliability, internal consistency and concurrent
validity; it is short, simple and can readily be incorporated
into clinical practice and research.
Despite its usefulness for measuring the wider experience
spectrum of stigma among PLMI, the Stigma Scale has not
been studied in non-Western population. As the experiences
of stigma are culturally sensitive, its applicability cannot be
assumed when used in a culture vastly different from its
origin. Hence, the aims of this study are to explore the
applicability of a Chinese version of the Stigma Scale (CSS)
among PLMI in Hong Kong, examine its psychometric
properties, and assess the relationships between different
facets of stigma with self-esteem and depression.
2. Methods
2.1. Participants and procedures
A cross-sectional survey with purposive sample was
adopted. Ethics approval was obtained through the Human
Research Ethics Committee of the authors' university. A total
of 114 community-dwelling PLMI were recruited via two
Integrated Community Centres for Mental Wellness (ICCMW)

200

A.H.Y. Ho et al. / Comprehensive Psychiatry 56 (2015) 198205

in Hong Kong. Respondents were service users of the two

community-based out-patient centers, they were approached by
members of staff or by the researchers, informed about the aim
of the study and invited to participate. Those who could not
read or understand Chinese were excluded from the study.
Upon informed consent, they completed a self-administered
questionnaire package.

2.2.4. Chinese Patient Health Questionnaire-9 (CPHQ9)

The Patient Health Questionnaire-9 is a screening instrument for depression [25]. Consisting of 9 items rated on a 4points Likert scale with higher scores indicating higher levels of
depressive symptoms, the CPHQ-9 has shown strong reliability
and predictive validity. It was included in this study to explore
the relationship between stigma and depression [26].

2.2. Measures

2.3. Statistical analysis

Participants were asked to fill in a number of demographic

items, followed by questions about the nature of their illness,
years since diagnosis as well as the type of treatment received.
Thereafter, they completed four standardized measures.

To explore the factor structure of the Chinese version of

the Stigma Scale, Mplus 7 [27] was used to carry out
exploratory factor analysis (EFA) on the original 28 items of
the scale to identify underlying factors. The items were
subject to maximum likelihood robust factor analysis with
oblique Geomin rotation. Missing data were handled via the
use of full-information maximum likelihood under the
missing at random assumption [27]. The original 28-item
three-factor EFA model was evaluated on the basis of the
following cutoff criteria on the goodness of fit indices:
insignificant 2 ( p N 0.05), comparative fit index
(CFI) 0.95, TuckerLewis index (TLI) 0.95, root mean
square error of approximation (RMSEA) 0.06, and standardized root mean square residual (SRMR) 0.08 [28].
In case of inadequate model fit, the scale items were screened
on the basis of the following criteria: significant factor loadings
on more than one factor, no significant loadings on any factors,
and low itemtotal correlations. The identified problematic
items were removed from the model in an iterative fashion until
an adequate EFA model was obtained. Eigenvalues and
proportions of explained variance were also taken into account
in determining the underlying factor structure. Table 1 shows the
original and the retained items of the Stigma Scale after the EFA.
Our analysis generated two EFA models, one with a two-factor
structure and one with a three-factor structure, these models
were compared and contrasted, and the one with the strongest
goodness of fit were retained.
CSS total score and its subscale scores were obtained by
adding together the corresponding item scores. Descriptive
statistics were obtained by averaging the items and subscales
scores on a 04 scoring range. Internal consistency was
assessed using the criterion on Cronbach's alpha ( 0.70)
[29]. Concurrent validity of the scale was evaluated by its
bivariate correlation with participants' demographic characteristics such as age, gender, years since diagnosis, and
validating scales including depression, self-esteem and selfstigma in relations to stereotype awareness, stereotype
agreement, self-concurrence and self-esteem decrement.
Significance level of this study was set at the .05 level.

2.2.1. Chinese Stigma Scale (CSS)

The English Stigma Scale [20] was translated into
Chinese by the fourth author who is fluently bilingual in
Chinese and English. The translated Chinese version was
then back-translated independently to English by the first
author. Discrepancies in sematic meaning between the
original English version and the back-translated Chinese
version were identified by two postgraduate students with
expertise in mental health research, and minor amendments
were made for correcting mistranslated words and improving
item presentation. This version was then examined by the
first and fourth author again for linguistic accuracy before
confirmation of the final text.
2.2.2. Chinese Self-stigma of Mental Illness Scale (CSSMIS)
The Self-stigma of Mental Illness Scale assesses PLMI's
sense of internalized stigma as a result of mental illness
discrimination [21]. It consists of four subscales: (1) stereotype
awareness, which represents perceived discrimination due to
social stigma; (2) stereotype agreement, which represents the
degree to which respondents agree with stigmatizing views;
(3) self-concurrence, which represents the degree to which
respondents apply stigmatizing views to themselves and other
PLMI; and (4) self-esteem decrement, which represents the
degree of harm to ones' self-esteem as a result of self-stigma.
Composed of 40 items rated on a 9-point Likert scale with
higher scores indicating higher levels of self-stigma, the
CSSMIS has shown strong reliability and various forms of
validity [22]. It was included in this study to examine the
concurrent validity of the CSS.
2.2.3. Chinese Self-Esteem Scale (CSES)
The Rosenberg Self-Esteem Scale consists of 10 items
that measures psychological well-being and self-efficacy
[23]. Rated on a 5-point Likert scale with higher scores
indicating higher levels of self-esteem, the CSES has shown
good strong reliability and concurrent validity [24]. It was
included in this study for examining the concurrent validity
of the CSS, as well as for exploring the relationship between
stigma and self-esteem.

3. Results
3.1. Participants' characteristics
All 114 participants were of Chinese ethnicity, 49.1%
were male and 50.9% were female. The mean age of the

A.H.Y. Ho et al. / Comprehensive Psychiatry 56 (2015) 198205

Table 1
Original and retained items of the Stigma Scale after EFA.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
26.
27.
28.

I have been discriminated in education because of my MHP

Sometimes I feel that I am being talked down to because of my MHP
Having had MHP has made me a more understanding person
I do not feel bad about having had MHP
I worry about telling people I receive psychological treatment (R)
Some people with MHP are dangerous
People have been understanding of my MHP (R)
I have been discriminated by police because of my MHP
I have been discriminated by employers because of my MHP
My MHP have made me more accepting of other people (R)
Very often I feel alone because of my MHP
I am scared of how others react if they find out about my MHP (R)
I would have had better chances in life if I had not had MHP
I do not mind people in my neighbourhood knowing I have had MHP
I would say I have had MHP if I was applying for a job
I worry about telling people that I take medicines/tablets for MHP (R)
People's reactions to my MHP make me keep myself to myself
I am angry with the way people have reacted to my MHP
I have not had any trouble from people because of my MHP (R)
I have been discriminated by health professionals due to my MHP (R)
People have avoided me because of my MHP (R)
People have insulted me because of my MHP (R)
Having had MHP has made me a stronger person (R)
I do not feel embarrassed because of my MHP (R)
I avoid telling people about my mental health problems (R)
Having had MHP makes me feel that life is unfair
I feel the need to hide my MHP from my friends (R)
I find it hard telling people I have MHP (R)

Italic items were removed after EFA. (R) = retained items. MHP = mental
health problems.

sample was 51.2 with a range of 20 to 79 years (SD = 11.34).

73.9% of the respondents were single, 17.1% were separated
or divorced and 9.0% were married. The majority had attained
secondary education (62.2%), roughly one-third had only
attained primary education (3.15%), and less than one-tenth
had attained tertiary education (6.3%). Most respondents were
diagnosed with schizophrenia (77.1%), others with depression
(7.6%), early psychosis (3.8%), bipolar disorder (2.9%), and
8.6% suffered from comorbid mental illnesses. The mean
years since diagnosis were 25.12 with a range of 1 to 55 years
(SD = 11.14); 58.6% had undergone counseling and psychotherapy, while the remaining 41.4% had received mostly
pharmacological treatments.
3.2. Factorial validity
As shown in Table 2, the original 28-item three-factor
EFA model showed a poor fit to the data with a highly
significant 2 and both CFI and TLI well below 0.95. A total
of 14 problematic items with double loadings or insignificant
loadings were removed from the model iteratively. We then
estimated a two-factor structure as well as a three-factor
structure for the revised 14-item EFA model. Results show
that the two-factor model displayed only a mediocre fit with
a highly significant 2, CFI and TLI b0.95 and RMSEA
N0.06. In contrast, the three-factor model displayed strong
goodness-of-fit across all indices with an insignificant 2,

201

CFI and TLI N0.95, and RMSEA and SRMR b0.04. Thus,
the three-factor model was retained as the final model.
3.3. Internal consistency
Table 3 shows the descriptive statistics and rotated factor
matrix for the revised 14-item three-factor EFA model. As
shown, the eigenvalue of the three factors was 4.54, 1.87,
and 1.23 for discrimination (4 items), disclosure (5 items)
and positive aspects (5 items), respectively; together
accounting for 54.6% of the total variance. In the model,
all 14 items loaded significantly onto their respective factors.
The Cronbach's alpha for discrimination, disclosure and
positive aspects were 0.84, 0.81, and 0.58, respectively;
and the Cronbach's alpha for the composite score of all
14 items was 0.83. While discrimination was significantly
and strongly associated with disclosure (r = 0.65, p b 0.01),
positive aspects was significantly but weakly associated
with other factors (r = 0.190.23, p b 0.05). Mean scores
were as follows: Chinese Stigma Scale 34.03 (SD = 9.19),
discrimination subscale 10.65 (SD = 4.91), disclosure
subscale 15.35 (SD = 5.58) and positive aspects subscale = 7.88 (SD = 4.22).
3.4. Concurrent validity
Table 4 shows the bivariate correlation between the
Chinese Stigma Scale, respondents' demographics, levels
of depressive symptoms as assessed by the CPHQ-9 and
the two validating scales of CSES and CSSMI. As shown,
the total stigma scale score and the discrimination subscale
score (high score indicates high perceived discrimination)
were negatively correlated with age (r = 0.34 and 0.27,
respectively) and men (r = 0.26 and 0.20, respectively).
The disclosure subscale score (high score indicates less
likely to disclose mental illness) was also negatively
correlated with the male gender (r = 0.25) but not with
age, while the positive aspects subscale score (high score
indicates less positive outlook on mental illness) was
positively correlated with age only (r = 0.20). Although
the CSS and none of its subscales correlated with education
level, years since diagnosis and types of treatment; total
stigma score associated positively with depression (r =
0.42), as with the discrimination subscale (r = 0.32) and the
disclosure subscale (r = 0.30). Moreover, total stigma,
discrimination, disclosure and positive aspects all correlated negatively with self-esteem (r = 0.57, 0.42, 0.30
and 0.37, respectively), and positively with the selfstigma dimension of stereotype agreement (r = 0.32, 0.32,
0.41 and 0.22, respectively). Finally, apart from positive
aspects, total stigma as well as discrimination and discourse
were positively correlated with the three self-stigma
dimensions of stereotype awareness (r = 0.51, 0.41 and
0.56, respectively), self-concurrence (r = 0.42, 0.31 and
0.46, respectively) and self-esteem decrement (r = 0.47,
0.34 and 0.48, respectively).

202

A.H.Y. Ho et al. / Comprehensive Psychiatry 56 (2015) 198205

Table 2
Goodness of fit indices of the EFA models on the Stigma Scale.
Model
description

df

CFI

TLI

RMSEA
(90% CI)

SRMR

1. Original
28-item,
3-factor
2. Revised
14-item,
2-factor
3. Revised
14-item,
3-factor

453.89

297

.807

.754

.068 (.055-.080)

.062

105.95

64

.869

.814

.076 (.049-.101)

.068

54.93

52

.991

.984

.022 (.000-.065)

.039

2: chi-square from maximum likelihood robust estimation; df: degree of

freedom; CFI: Comparative fit index; TLI: TuckerLewis index; RMSEA
(90% CI): Root mean square error of approximation (90% confidence
interval); SRMR: standardized root mean square residual.
p b 0.01.

4. Discussion
The goals of this study were to examine the applicability,
reliability and validity of a Chinese version of the Stigma
Scale for clinical and research proposes, as well as to explore
the relationships between different facets of stigma with selfesteem and depression in the Chinese context. To this end,
we have successfully translated the Stigma Scale into
Chinese and examined its psychometric properties with a
representative community sample of PLMI in Hong Kong.
Our findings supported the applicability of the CSS, as there
were no reports of difficulties for completing the instrument
and all participants understood the instructions as well as the

meaning of each individual item. Some participants expressed

an appreciation for the positive tone used in the CSS as
opposed to the harsh voice found in CSSMIS [22]. Moreover,
the completion time of approximately 510 minutes for the
shorten 14-item CSS can promote wider use in the community
and serve as an ideal screening tool for most clinical and social
care settings. With reduced assessment burden, it can easily be
adopted for large scale empirical research to advance our
understanding on mental health stigma among PLMI of
different Chinese communities.
4.1. Reliability, validity and clinical implications
Although the original 28-item three-factor model was a
poor fit to our data, the revised 14-item three-factor structure
was found to be a good fit with all 14 items loaded
significantly onto the original factors of discrimination,
disclosure and positive aspects. Reliability data supported
the internal consistencies of the 14-item CSS, with moderate
to good homogeneity on the total stigma scale and its three
subscales. The alpha levels and inter-correlations of
subscales found in this study were also similar to those
reported by King et al. [20]. Specifically, the strong
association between the discrimination subscale and the
disclosure subscale suggests that Chinese PMLI who felt
discriminated through social stigma are more likely to avoid
disclosure for fear of stereotyping and labeling. Yip [30]
reported comparable findings in his Hong Kong study as he
commented that public labeling had prevented mental health
service users from disclosing their illness to others, thus
seriously hindering their community integration leading to

Table 3
Descriptive statistics and rotated factor matrix for the revised 14-item Stigma Scale.
Item
Factor 1: Discrimination (Cronbach's alpha = .84)
I worry about telling people that I take medicines/tablets for MHP
I have been discriminated by health professionals due to my MHP
People have avoided me because of my MHP
People have insulted me because of my MHP
Factor 2: Disclosure (Cronbach's alpha = .81)
I worry about telling people I receive psychological treatment
I am scared of how others react if they find out about my MHP
I avoid telling people about my MHP
I feel the need to hide my MHP from my friends
I find it hard telling people I have MHP
Factor 3: Positive aspects (Cronbach's alpha = .58)
People have been understanding of my MHP
My MHP have made me more accepting of other people
I have not had any trouble from people because of my MHP
Having had MHP has made me a stronger person
I do not feel embarrassed because of my MHP
Total factor scores (SD)
Average factor mean (SD)
Eigenvalue
Proportion of explained variance

Mean (SD)
1.92 (1.48)
1.53 (1.45)
1.69 (1.52)
1.63 (1.41)

Factor 1

Factor 2

Factor 3

.70
.61
.79
.75

2.14 (1.45)
2.04 (1.48)
1.95 (1.46)
1.86 (1.47)
2.17 (1.48)

.52
.50
.65
.97
.62

1.66 (1.39)
1.28 (1.35)
1.84 (1.60)
1.25 (1.27)
1.84 (1.47)
10.65 (4.91)
1.66 (1.23)
4.54
32.5%

15.35 (5.58)
2.08 (1.12)
1.87
13.4%

.40
.36
.63
.62
.33
7.88 (4.22)
1.58 (0.84)
1.23
8.8%

Maximum likelihood robust estimation with Geomin rotation. Factor loadings less than .2 are suppressed. All shown factor loadings are significant at .05 level.
MHP = mental health problems. Each item/factor is scored on a 04 scale.

A.H.Y. Ho et al. / Comprehensive Psychiatry 56 (2015) 198205

Table 4
Correlations between Stigma Scale, demographics, and validating scales
(N = 114).

Age
Gender (male)
Education level
Years since diagnosis
Types of treatment
(medication)
Depression (CPHQ-9)
Self-esteem (CSES)
Self-stigma (CSSMI)
Stereotype awareness
Stereotype agreement
Self-concurrence
Self-esteem decrement

Total
stigma

Discrimination Disclosure Positive

aspects

.34
.26
.49
.15
.24

.27
.20
.84
.11
.26

.42
.32
.57 .42
.51
.32
.42
.47

.41
.32
.31
.34

.19
.25
.47
.08
.13

.20
.04
.30
.08
.16

.30
.30

.19
.37

.56
.41
.46
.48

.14
.22
.02
.01

p b 0.05.
p b 0.01.

social exclusion. Conversely, the weaker associations

between the positive aspects subscale with the discrimination
and disclosure subscales may reflect that Chinese PLMI who
were more accepting of their mental illness were more open
to making positive changes, and hence were less affected
by stigma. These results underline that PLMI would benefit
from interventions that facilitate both introspection and
expression of their experiences with mental illness so as to
derive at greater levels of self-understanding and selfacceptance. Moreover, anti-stigma campaigns that foster
community dialogues between PLMI and the public can
cultivate social understanding and authentic empathy,
leading to the alleviation of prejudice and discrimination.
Recent research has highlighted the robust potential of art
therapy for nurturing self-appreciation, social dialogues and
empowering partnerships to promote positive changes in
mental health inclusion [31,32]. Clearly, art therapy can
be competently adopted in psychiatric rehabilitation for
promoting growth and transformation, while the role of art in
the eradication of social stigma and discrimination warrants
future investigations.
It is important to note that the items that were removed
from the original scale tend to be context specific and
emotion focused (i.e. I am angry with the way people have
reacted to my mental health problems; I have been
discriminated by the police/by employers because of my
mental health problems), and this may point towards a
cultural discrepancy in how Western and Chinese individuals react to authorities and situations that disrupt social
harmony. In fact, Phillips et al. [33] reported that the
damaging effects of stigma on Chinese PLMI are significantly greater for those with higher levels of negatively
expressed emotions within the family system, as criticism
and hostility formed anxious and destructive interaction

203

patterns that could lead to the internalization of negative selfimage. Hence, given the cultural tendency to reserve
emotions for avoiding conflicts, more general items, which
enquire about situations but without the potential shame of
naming specific individuals or groups, seem more appropriate for assessing stigma among Chinese PLMI. Accordingly,
the CSS can competently and adequately identify those
who are at greater risks for emotional disturbances due to
discrimination, fear of discourse and a negative outlook on
mental illness.
Our data supported the validity of the CSS. Specifically,
the total stigma scale and its three subscales of discrimination, disclosure and positive aspects were inversely and
significantly related to self-esteem. Significant positive
associations were also found between total stigma, discrimination and disclosure with stereotype awareness, stereotype
agreement, self-concurrence and self-esteem decrement.
These relationships demonstrate the concurrent validity of
the instrument and its subscales. Interestingly, while total
stigma, discrimination and disclosure were significantly
associated with depression, positive aspects was not; this
finding provides further evidence that Chinese PLMI who
were able to accept their illness and construct a more positive
self-identity as well as outlook on life were less likely to be
affected by depression as a result of stigma [1417]. These
findings once again accentuate the vast potential of art
therapy for enhancing psychiatric rehabilitation and mental
health intervention and promotion. Finally, our data suggest
that older PLMI were more likely to feel discriminated
against and less likely to find positive aspects through their
experiences, while female PLMI were less likely to disclose
their illness due to discrimination and thus limiting their
opportunity for support. Preventive measures should target
these specific population groups who are at greater risk of the
adverse effect of social and self-stigma.
4.2. Strengths, limitations and future directions
This is the first study that successfully translated the
Stigma Scale and examined its psychometric properties
among a representative community sample of Chinese
PLMI. While the clinical and research utility of the CSS
for assessing the multifaceted nature of mental illness stigma
is supported by our findings, there are several limitations.
First, although the sample size of 114 was adequate for factor
analysis with 28 variables and 3 factors [34], this number of
participants could only provide a general impression but not
a comprehensive picture of the experience of mental illness
stigma among Chinese PLMI in Hong Kong. In order to gain
a more in-depth understanding of the severity and impact of
stigma, a much larger sample that includes both communitydwelling and institutionalized PLMI is needed. Second, this
study was based on cross-sectional data and did not include a
stability assessment of the CSS, thus, future research should
include a testretest reliability evaluation with longitudinal
data. Third, the clinical implications derived from our study

204

A.H.Y. Ho et al. / Comprehensive Psychiatry 56 (2015) 198205

should not be fully generalized to all Chinese PLMI in other

countries due to the potential differences in societal attitudes
towards mental illness, and future research should be carried
out with other Chinese groups in different parts of the world.
Despite these limitations, our study supported the
applicability and validity of the CSS in all Chinese speaking
contexts. Instruments that can competently measure the
diverse experience and impact of stigma on PLMI with low
assessment burden are pivotal for informing and evaluating
clinical interventions and mental health promotion programs
that gear towards recovery, community integration and stigma
alleviation. Given the devastating impact of mental illness
stigma on individual and public health as well as the need for
greater mental health inclusion worldwide, the CSS will play
an important role in establishing an evidence-based foundation
for stigma changing practices in Hong Kong and other Chinese
communities around the globe.

Declaration of Interest
No Conflict of Interest.

Funding
This study was funded by the Public Policy Research Scheme,
Research Grant Council, Hong Kong SAR Government
(Ref. No.: HKU 7006-PPR-11).
Acknowledgment
We would like to express our gratitude to all participants
and staffs of the Providence Garden for Rehab, Hong Kong
Sheng Kung Hui Welfare Council, and those from the Lok
Hong Integrated Community Centre for Mental Wellness,
Tung Wah Group of Hospitals, for their kindest contributions
and assistances to this study.
References
[1] Holmes EP, River LP. Individual strategies for coping with the stigma
of severe mental illness. Cogn Behav Pract 1998;5:231-9.
[2] Tsang HWH, Tam PKC, Chan F, Cheung WM. Stigmatizing attitudes
towards individuals with mental illness in Hong Kong: implications for
their recovery. J Community Psychol 2003;31:383-96.
[3] Corrigan PW, Watson AC. The paradox of self-stigma and mental
illness. Clin Psychol Sci Pract 2002;9:35-53.
[4] Wright SC, Taylor DM, Moghaddam FM. Responding to membership
in a disadvantaged group: from acceptance to collective protest. J Pers
Soc Psychol 1990;58:994-1003.
[5] Hong Kong Hospital Authority. Hospital Authority Mental Health
Service Plan for Adult 20102015. Hong Kong Hospital Authority;
2011.
[6] Health Check. Hong Kong conducts first mental health survey. BBC
News [newspaper online]; 2011. [cited 2013 Jan 15. Available from:
BBC News. http://www.bbc.co.uk/news/health-13687793].

[7] Chung KF, Wong MC. Experience of stigma among Chinese mental
health patients in Hong Kong. Psych Bulletin 2004;28:451-4.
[8] Tsang HW, Tam PK, Chan F, Cheung WM. Sources of family
burden of individuals with mental illness. Int J Rehabil Res
2003;26:123-30.
[9] Tsang HW. Applying social skills training in the context of vocational
rehabilitation for people with schizophrenia. J Nerv Ment Dis
2001;189:90-8.
[10] Tsang D. Policy address: sharing prosperity for a caring society. Hong
Kong: Hong Kong SAR Government Press; 2012.
[11] Link BG, Yang LH, Phelan JC, Collins PY. Measuring mental illness
stigma. Schizophr Bull 2004;30:511-41.
[12] Livingston JD, Boyd JE. Correlates and consequences of internalized
stigma for people living with mental illness: a systematic review and
meta-analysis. Soc Sci Med 2010;71:2150-61.
[13] Dinos S, Steven S, Serfaty M. Stigma: the feelings and experiences of
46 people with mental illness: qualitative study. Br J Psychiatry
2004;184:176-81.
[14] Finlay WML, Dino S, Lyons E. Stigma and multiple social
comparisons in people with schizophrenia. Eur J Soc Psychol
2001;31:579-92.
[15] Camp DL, Finlay WML, Lyons E. Is low self-esteem inevitable in
stigma? Soc Sci Med 2002;55:823-34.
[16] Rusch N, Lieb K, Bohus M, Corrigan PW. Self-stigma, empowerment,
and perceived legitimacy of discrimination among women with mental
illness. Psychiatr Serv 2006;57:399-402.
[17] Shih M. Positive stigma: Examining resilience and empowerment in
overcoming stigma. Ann Am Acad Pol Soc Sci 2004;591:175-85.
[18] Link BG, Struening EL, Teese-Tood S, Asmussen S, Phelan JC.
Stigma as a barrier to recovery: the consequences of stigma for the selfesteem of people with mental illnesses. Psychiatr Serv
2001;52:1621-6.
[19] Corrigan PW, Michaels PJ, Vega A, Gause M, Watson AC, Rusch N.
Self-stigma of mental illness scaleshort form: reliability and validity.
Psychiatry Res 2012;199:65-9.
[20] King M, Dinos S, Shaw J, Watson R, Stevens S, Passetti F, et al. The
Stigma Scale: development of a standardized measure of the stigma of
mental illness. Br J Psychiatry 2007;190:248-54.
[21] Corrigan PW, Watson AC, Barr L. The self-stigma of mental illness:
implications for self-esteem and self-efficacy. J Soc Clin Psychol
2006;25:875-84.
[22] Fung KMT, Tsang HWH, Corrigan PW, Lam CS, Cheng WM.
Measuring self-stigma of mental illness in China and its implications
for recovery. Int J Soc Psychiatry 2007;53:408-18.
[23] Rosenberg M. Conceiving the self. Krieger Publishing Company; 1979.
[24] Colin RM, Thompson DR, Chan DS. An examination of the
psychometric properties of the Rosenberg Self-Esteem Scale in
Chinese acute coronary syndrome patients. Psychol Health Med
2007;11:507-21.
[25] Spitzer RL, William JB, Kroenke K. The PHQ-9: validity of a brief
depression severity measure. J Gen Intern Med 2001;16:606-13.
[26] Yu X, Tam WW, Wong PT, Lam TH, Stewart SM. The
Patient Health Questionnaire-9 for measuring depressive symptoms
among the general population in Hong Kong. Compr Psychiatry
2012;53:95-102.
[27] Muthen LK, Muthen BO. MPlus user's guild. 7th ed. Muthen &
Muthen; 19982012.
[28] Hu LT, Bentler PM. Cuffoff criteria for fit indexes in covariance
structure analysis: conventional criteria versus new alternatives. Struct
Equ Model 1999;6:1-55.
[29] Nunnally JC, Berstein IH. Psychometric theory. 3rd ed. McGraw-Hill; 1994.
[30] Yip KS. Coping with public labeling of clients with mental illness in
Hong Kong: a report of personal experiences. Int J Psychosoc Rehabil
2005;9:1-15.
[31] Spaniol S, Bluebird G. Report: creative partnershippeople with
psychiatric disabilities and art therapists in dialogue. Art Psychother
2009;29:107-14.

A.H.Y. Ho et al. / Comprehensive Psychiatry 56 (2015) 198205

[32] Potash J, Ho RTH. Drawing involves caring: foster relationship
building through art therapy for social change. Art Ther 2011;28:74-81.
[33] Phillips MR, Person V, Li F, Xu M, Yang L. Stigma and expressed
emotion: a study of people with schizophrenia and their family
members in China. Br J Psychiatry 2002;181:488-93.
[34] Arrindell WA, van der Ende J. An empirical test of the utility of
the observations-to-variables ratio in factor and components analysis.
Appl Psychol Meas 1985;9:165-78.
Andy, H.Y. Ho, PhD, MFT, FT Assistant Professor, Division of
Psychology, School of Humanities and Social Sciences, Nangyang Technological University, Singapore; Honorary Research Fellow, Centre on
Behavioral Health, and Sau Po Centre on Ageing, The University of Hong
Kong, Hong Kong. HSS-04, 14 Nanyang Drive, Singapore 637332. Tel: (852)
60121886; Email: andyhyho@gmail.com

Jordan S. Potash, PhD, ATR-BC, REAT, LCAT Visiting Assistant

Professor, Art Therapy Program, The George Washington University, USA;
Honorary Assistant Professor, Centre on Behavioral Health, and Department
of Social Work & Social Administration, The University of Hong Kong.
1925 Ballenger Avenue, Suite 250, Alexandria, VA 22314. Tel: (703) 299
4148 Email: jordan@jordanpotash.com

Ted C. T. Fong, MPhil Senior Research Assistant, Centre on Behavioral

Health, The University of Hong Kong. 2/F, The HKJC Building
for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong.
Tel: (852) 28315174; Email: ttatt@hku.hk

205

Vania F. L. Ho, BA Research Coordinator, Centre on Behavioral Health,

The University of Hong Kong. 2/F, The HKJC Building for Interdisciplinary
Research, 5 Sassoon Road, Pokfulam, Hong Kong. Tel: (852) 28315202;
Email: hovania@hku.hk

Eric Y. H. Chen, MD, FRCPsyc Professor, Department of Psychiatry,

The University of Hong Kong. Queen Mary Hospital, 102 Pokfulam Road,
Hong Kong. Tel: (852) 22553063; Email: eyhchen@hku.hk

Robert H. W. Lau, MSocSc Team Leader, Lok Hong Integrated

Community Centre for Mental Wellness, Tung Wah Group of Hospital.
TWGHs Wong Chuk Hang Complex 2 Wong Chuk Hang Path, Wong Chuk
Hang, Hong Kong. Tel: (852) 28162837; Email: cmhcs@tungwah.org.hk

Friendly S. W. Au Yeung, MSocSc Chief Manager, The Providence

Garden for Rehab, Hong Kong Sheng Kung Hui Welfare Council. 82
Tsun Wen Road, Tuen Mun, N.T. Hong Kong. Tel: (852) 35110951;
Email: fauyeung@skhwc.org.hk

Rainbow, T. H. Ho, PhD, BC-DMT, CMA Director, Centre on

Behavioral Health; Associate Professor, Department of Social Work and
Social Administration, The University of Hong Kong; 2/F, The HKJC
Building for Interdisciplinary Research, 5 Sassoon Road, Pokfulam, Hong Kong;
Tel: (852) 28315169; Email: tinho@hku.hk