Whilst most mental illnesses may be associated with some degree of stigma, schizophrenia has been described as “a modern day equivalent of leprosy”, conferring unparalleled social ostracism to the person with schizophrenia and their family
. Stigma comprises of three elements: problems of knowledge (misinformation), problems of attitudes (prejudice), and problems of behaviour (discrimination)
Furthermore, two major classes of stigma are recognized: public stigma and personal stigma. Public stigma (or social stigma) typically describes the endorsement of stereotypes and enacted behaviours against people with mental illness by professionals and the general population
]. Personal experiences of stigma, measured in those with mental illness, can be considered in three ways
Perceived stigma: what the individual thinks are society’s beliefs about the stigmatized group
Experienced stigma: actual discrimination experienced
Self-stigma: a product of the internalization of public stigma
In internalized stigma or self-stigma, a gradual process of psychological assimilation of the public stereotypes towards mental illness is said to occur such that the person with mental illness progressively loses what they think they are and wish to be in the future
. In essence, the person not only believes that others think s/he is not worthwhile or should not, for example be married, but also believes that s/he is not actually worth much and should not be married. This changes fundamentally the perception the person has about themselves and leads to a change in the person’s behaviour in a way that matches the internalized perceptions. Until recently most research has focused on public stigma rather than internalized stigma
. Several studies have emphasized the negative consequences of such negative perceptions and behaviour, including loss of self-esteem and self-efficacy, disempowerment, demoralization and loss of income
[5–8]. Clinically, higher depressive symptoms, increased suicidality and poorer medication adherence are also reported
. Because of the above consequences and related negative impacts such as social withdrawal, poor vocational functioning and worse quality of life
[5–7, 9–14], internalized stigma is emerging as a key factor that can hold back the recovery process.
Stigma is a major problem across different societies, but the particular manifestations of stigma may vary. Variation in the interaction between stigma and mental illness is evident in different settings
. Stigma is also considered an important explanatory factor for the better outcome of schizophrenia in low income settings
. Families in developing societies have been described as “supportive and tolerant” and that there is “little risk of prolonged rejection, isolation, segregation and institutionalisation”
. In the developed societies that emphasize individuality, it is proposed that loss of employment would mean loss of status and self-esteem and rejection. The person with the illness takes responsibility for the illness and its consequences. Although these principles are relevant, making broad generalizations cannot always hold true. For example, in cultures where stigma is considered to be a moral issue, it may threaten what “matters most” for those living in the local world
[18, 19]. Moreover, if the proposition about persons from low income setting taking less individual responsibility is correct, this is likely to be replaced by the responsibility they feel for their family. Thus a person from low income settings would feel responsible for the consequences of the illness on the family experiencing the illness not only as a personal tragedy but that they have caused disgrace to the family by becoming ill, and that the condition may have devastating consequences on the social standing of the family. Although our study has not explored these broader cultural issues, we consider that the level of stigma is likely to reflect the broader personal and family implications of having a mental illness.
Most of our understanding about internalized stigma originates from high-income countries. Yet the few available studies have demonstrated high levels of internalized stigma amongst patients with schizophrenia in some African countries: Ghana
 and South Africa
. There has been no previous assessment of internalized stigma in Ethiopia. The only reported study concerning stigma in severe mental disorders in Ethiopia looked at perceived stigma among 178 carers of persons with schizophrenia and major affective disorders
. This study was part of a large community-based project in Southern Ethiopia
. About 75% of the caregivers reported experiencing stigma. Urban residence and older age were the main factors associated with higher experience of stigma. The finding suggests that the experience of internalized stigma may also be high
Systematic investigation of the extent and correlates of internalized stigma is an essential part of planning for recovery programs for schizophrenia. This research is timely for the Ethiopian setting and other low-income country settings as mental health services are undergoing a shift towards primary health care and community settings
. Community-based rehabilitation (CBR) for people with schizophrenia, including social and vocational rehabilitation, will form part of the services under development. An understanding of the stigma and discrimination experienced by this group is vital to developing appropriate training materials for the community health workers who will deliver the CBR. Anti-stigma campaigns are gaining prominence in high-income countries
. For low-income countries to follow suit a more detailed understanding of the extent and nature of the stigma related to mental illness is required. This will also allow evaluation of the effectiveness of anti-stigma campaigns.
The primary objective of the study was to assess the extent of internalized stigma among patients with schizophrenia attending the outpatient department of a psychiatric hospital in Ethiopia. Related to this we aimed to determine which socio-demographic and clinical factors are associated with the experience of stigma and to explore the potential impact of stigma on medication adherence and risk behaviour; important factors that may affect the recovery process.