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Running head: HONOR AND STIGMA OF MENTAL HEALTHCARE 1
Honor and the Stigma of Mental Healthcare
Ryan P. Brown
Mikiko Imura
Lara Mayeux
The University of Oklahoma
[This is a copy of the accepted manuscript, published in Personality and Social Psychology
Bulletin, 2014]
Author Note
Correspondence should be directed to Ryan P. Brown, Department of Psychology, University of
Oklahoma, 445 W. Lindsey St., DHT 705, Norman OK, 73019; phone: 405-325-4526.
HONOR AND STIGMA OF MENTAL HEALTHCARE 2
Abstract
Most prior research on cultures of honor has focused on interpersonal aggression. The present
studies examined the novel hypothesis that honor-culture ideology enhances the stigmatization of
mental health needs and inhibits the use of mental health services. Study 1 demonstrated that
people who strongly endorsed honor-related beliefs and values were especially concerned that
seeking help for mental health needs would indicate personal weakness and would harm their
reputations. Studies 2 and 3 showed that honor states in the US South and West invested less in
mental healthcare resources, compared to non-honor states in the North (Study 2), and that
parents living in honor states were less likely than parents in non-honor states to use mental
health services on behalf of their children (Study 3). Together, these studies reveal an overlooked
consequence of honor ideology for psychological well-being at the individual, social, and
institutional levels.
Keywords: honor, culture, stigma, mental health
Word count: 143
HONOR AND STIGMA OF MENTAL HEALTHCARE 3
Honor and the Stigma of Mental Healthcare
Mental illness is associated in many cultures with a variety of negative stereotypes,
including being dangerous, unpredictable, and weak. Such stereotypes, and the discriminatory
treatment that can accompany such stereotypes (Corrigan & Matthews, 2003) can serve as
powerful motivators to deny membership in the category of “the mentally ill” (e.g., Quinn &
Chaudoir, 2009) and to avoid utilizing mental health services (Corrigan, 2004). Almost one-third
of the adolescent participants in a recent survey reported that they were not at all willing to seek
out mental health services, even if they felt that they needed them (Chandra & Minkovitz, 2006).
Of particular concern to adolescents was the belief that seeing a professional for mental
healthcare makes peers “think you are weird or different” and that seeing a counselor indicates
personal weakness. Research has likewise uncovered stigma-related barriers to services among
the parents of adolescents with mental health needs, who often report feelings of embarrassment,
concerns about labeling their child as “mentally ill,” and the fear of being seen as a bad parent,
all of which can serve as deterrents to seeking help for their child (Sayal et al., 2010). Indeed,
Muhlbauer (2002) reported that parents’ concerns about the stigma-by-association (or “courtesy
stigma”) associated with seeking mental health services for children included self-stigma, stigma
from family members, and stigma from institutions (e.g., insurance companies, doctors).
Faced with multiple sources of stigma, people with mental health needs are likely to
avoid seeking help. In the present paper, we suggest that such impediments to accessing mental
health services might be further understood by examining the stigma of mental healthcare at a
cultural level. Specifically, the present research investigates a socio-cultural influence on the
stigmatization of mental healthcare deriving from the beliefs and values of the culture of honor
(Nisbett, 1993; Nisbett & Cohen, 1996). As we will describe, the beliefs and values of honor
HONOR AND STIGMA OF MENTAL HEALTHCARE 4
cultures that have been linked to aggression and violence are likely to enhance the stigmatization
of mental health needs and the receipt of care for those needs.
Mental Healthcare and the Culture of Honor
Honor cultures exist all around the world, including the nations of the Middle East, many
societies around the Mediterranean and in Central and South America, as well as the southern
and western regions of the United States (e.g., Nisbett & Cohen, 1996; Peristiany, 1966;
Vandello, Cohen, Grandon, & Franiuk, 2009). Although every culture defines what traits and
behaviors it values, cultures of honor place special emphasis on the importance of reputation as a
primary feature of individual and collective identity. For men in such cultures, having honor
means being (and being known as) strong, capable, and willing to defend one’s person, family,
and property. For women in such cultures, having honor primarily means being loyal and
sexually chaste, although strength and toughness may also be of some importance (see Barnes,
Brown, & Tamborski, 2012). Failure to fulfill these gender-specific ideals brings shame to
oneself and to one’s family, which can be difficult or impossible to erase (Fischer, 1989;
Peristiany, 1966; Vandello & Cohen, 2003; Wyatt-Brown, 1986).
Based largely upon the massive immigrations of the Ulster Scots, or “Scotch-Irish”
(Fischer, 1989; Leyburn, 1962; Nisbett, 1993) to parts of the United States during the 17th and
18th centuries, Nisbett and colleagues (e.g., Nisbett & Cohen, 1996) have identified “honor
states” as those categorized by the US Census Bureau within the southern or western regions,
with the exception of Hawaii and Alaska, which, although officially categorized as “western,” do
not share in the cultural heritage of other southern and western states (e.g., Vandello & Cohen,
1999). Thus, along with Hawaii and Alaska, all non-southern/non-western states are identified by
Nisbett and colleagues as non-honor states. Following this regional classification, research has
HONOR AND STIGMA OF MENTAL HEALTHCARE 5
demonstrated a host of differences between honor states and non-honor states in the realm of
male aggression. For example, honor states exhibit significantly higher rates of argument-based
homicide among Whites, but not among non-Whites, compared to non-honor states (Cohen,
1998; Nisbett & Cohen, 1996; see also Lee, Bankstron, Hayes, & Thomas, 2007), a pattern that
Brown, Osterman, and Barnes (2009) expanded to the realm of school violence. Lab experiments
have likewise demonstrated that males from honor states exhibit different cognitive, behavioral,
and physiological responses to insults compared with males from other states, including
increases in cortisol and testosterone, and a higher likelihood of engaging in aggressive and
dominant behaviors (Cohen, Nisbett, Bowdle & Schwarz, 1996).
Recent studies have extended this research on interpersonal violence to violence against
the self (Osterman & Brown, 2011), showing that people living in honor states in the US South
and West have higher rates of suicide than people living in non-honor states in the North,
especially if they are White and live in small towns. These demographic qualifiers of suicide
rates are generally consistent with previous research on honor and homicide, although evidence
that women in honor states also commit suicide at increased rates was a novel finding. This
similarity across gender is one of the first such demonstrations in the honor-culture literature to
date (see also Barnes, Brown, & Tamborski, 2012). Osterman and Brown also argued that people
in honor states might be less likely to seek help for their feelings of distress. Consistent with this
idea, they found that statewide levels of severe depression (which were significantly higher in
honor states) were positively associated with statewide suicide rates, but only among honor
states, and that anti-depressant prescription rates (which were higher in non-honor states) were
negatively associated with suicide, but only among non-honor states. If anti-depressant
prescription rates reflect help-seeking behaviors, then this might explain the disconnect between
HONOR AND STIGMA OF MENTAL HEALTHCARE 6
depression rates and suicide rates among non-honor states—specifically, in places where people
tend to seek help for their distress (e.g., in non-honor cultures), rates of distress should be more
disconnected from rates of suicide, whereas in places where people tend to avoid seeking help
(e.g., in honor cultures), distress and suicide ought to be positively associated.
Building upon these findings, we hypothesize that in addition to aggression against others
or the self, the ideology of honor might manifest itself in an enhanced stigmatization of seeking
help for mental health needs. After all, if the point of aggressive retaliation is to restore or assert
one’s reputation by a show of strength, then any act suggestive of weakness could undermine this
goal. Admitting that one needs help—especially the kind of help offered by mental healthcare
professionals—ought to be devalued within a culture of honor, leading to a culturally-enhanced
stigma that could produce a multi-faceted barrier to accessing mental healthcare services.
Research has also linked the stigma of seeking help for mental health needs with broad
social norms regarding gender roles, particularly among men (e.g., Pleck, Sonenstein, & Ku,
1994). Such studies tend to focus almost exclusively on men’s definitions of masculinity and
associate their beliefs about gender role expectations (their own or others’) with difficulties in
admitting their needs for assistance or discussing problems associated with emotions. Although
research on masculinity beliefs is related to honor-based ideologies and their transmission, a
generic approach to gender definitions and roles will tend to conflate culturally relevant
constructs and will tend to measure beliefs and values at too broad a level. Thus, a more nuanced
approach to measuring beliefs and values deriving from honor ideology is needed if we hope to
pinpoint the cultural influences that might enhance the stigmatization of mental healthcare.
A cultural perspective on gender definitions would lead us to examine the extent to which
both men and women embrace the cultural ideology of honor, and the extent to which this
HONOR AND STIGMA OF MENTAL HEALTHCARE 7
embracing of honor norms is associated with the stigma of mental healthcare. Indeed, women
might feel almost as stigmatized as men would for utilizing mental healthcare services if they
live in a culture of honor, as the values of toughness and self-reliance that the culture of honor
extols for men are also of some value for women (Barnes, Brown, & Tamborski, 2012).
Research has also shown that honor is not just about personal reputations, but also collective
reputations, including the reputation of one’s family (e.g., Barnes, Brown, & Osterman, 2012;
Rodriguez-Mosquera, Manstead, & Fischer, 2002). Thus, women might feel reticent to seek help
for mental health needs in part to reduce the indirect impact of courtesy stigmas experienced by
those associated with them, such as family members, spouses, and friends, and perhaps also
because their loved ones might explicitly dissuade them from seeking help in order to avoid a
courtesy stigma (Barney, Griffiths, Jorm, & Christensen, 2006). Furthermore, although “purity
concerns” for women in the honor literature relate almost exclusively to sexual purity, we think it
is also plausible that mental health needs might be subtly linked to a form of impurity, leading to
a perception of mental health needs as representing a type of “psychological infection” (Turner,
2000). This might create a purity-related barrier to acknowledging or seeking help for mental
health needs among women in an honor culture. Women’s purity concerns, again, can affect their
whole family’s honor. The sources of pressure for women to avoid psychological treatment
might thus be somewhat different from that for men, though just as serious. Even apart from
these individual-level concerns, however, if the stigma of mental healthcare leads to a reduction
in social investments in mental health services, then this investment deficit will have
implications for both men and women. A person cannot utilize services that do not exist, no
matter how motivated they might be to do so.
In the present studies, we extend prior research on the culture of honor to the unique
HONOR AND STIGMA OF MENTAL HEALTHCARE 8
domain of mental healthcare stigmatization, examining honor ideology at both the individual and
regional levels. Study 1 uses an individual level of analysis, connecting the endorsement of
honor-related beliefs and values to attitudes toward seeking mental healthcare. Study 2 examines
deficits in mental healthcare services as a function of regional differences in honor-culture status.
Finally, Study 3 examines parents’ utilization of available mental health services on behalf of
their children, again as a function of regional differences in honor culture.
Study 1
Research on honor dynamics in the US has traditionally compared respondents from
honor regions and non-honor regions, which we do as well in Studies 2 and 3 (e.g., Cohen, 1998;
Cohen et al., 1996). However, this method overlooks the important individual variability within
cultures. Not all members of a culture agree with its ideology, creating intra-cultural variability
(e.g., Leung & Cohen, 2011).
Study 1 addresses this intra-cultural variability by examining people’s endorsement of
honor-related beliefs and values as a predictor of concerns about seeking mental healthcare
services. The measure of honor ideology endorsement used in this study is a measure recently
constructed by Barnes, Brown, & Osterman (2012) called the honor ideology for manhood scale
(or HIM). This measure focuses on the masculine dimension of honor ideology, in part because
this dimension is the most well-studied aspect of honor beliefs and values, and in part because
beliefs about “real manhood” seem to be among the most consistent features of honor cultures
around the world, whereas other dimensions seem to be more variable across honor cultures
(e.g., specific beliefs about femininity).
The validity and predictive utility of the HIM has been demonstrated in a diverse array of
studies recently, which have shown that scores on this scale are associated with responses to
HONOR AND STIGMA OF MENTAL HEALTHCARE 9
terrorist attacks (Barnes et al., 2012), symptoms of depression (Osterman & Brown, 2011),
excessive risk-taking (Barnes, Brown, & Tamborski, 2012), and even an implicit index of honor
endorsement (Imura, Burkley, & Brown, 2014). The latter three findings come from studies that
included both men and women, and the authors report that no significant gender differences in
associations were obtained across this diverse array of outcomes, thus supporting the validity of
the HIM as a measure of honor endorsement for both men and women. Because this scale is
ideological rather than self-descriptive, both men and women can endorse (or reject) the items of
the HIM, and their endorsement would reflect their embracing of one of the central features of
the ideology of honor regardless of their gender. Thus, scores on the HIM might predict the
stigma of mental healthcare as effectively among women as among men, although the precise
nature of their stigma-related concerns could certainly differ.
In the current study, we examined the relationship between honor ideology and two
dimensions of the stigmatization of mental healthcare that have been identified in previous
studies (Corrigan, 2004): personal concerns (i.e., an internalized sense of self-criticism for
having needed and sought help for mental health needs), and social concerns (i.e., fears about
criticisms or devaluation by others if they should discover one’s use of mental healthcare
services). We also included measures of impression management and self-esteem to enhance our
confidence that any association we might find between honor ideology endorsement and personal
or social concerns was not simply the result of these potential confounds.
Method
Participants. Seven hundred fifty-six respondents (258 males, 498 females) who
identified themselves as White (74.5%), Black (4.9%), Native American (5.0%),
Hawaiian/Pacific Islander/Asian (8.9%), Hispanic (4.5%), or Other (2.1%) participated.
HONOR AND STIGMA OF MENTAL HEALTHCARE 10
However, for the sake of consistency with Study 3, which only included White, non-Hispanic
participants (due to the regional proxy for culture-of-honor status, as opposed to a direct measure
of individual endorsement of honor ideology), we only included the data from White, non-
Hispanic respondents in this study. This selection left 563 students (185 male, 378 female) for
our analyses (we should note that the results remain largely unchanged when we include data
from all participants). Participants were all students at a large, Midwestern university, who
participated in exchange for credit in an introductory psychology course. Participants’ mean age
was 18.97 years (SD = 1.46).
Materials.
Honor ideology for manhood (HIM; Barnes et al., 2012). The 16-item HIM scale (α =
.92) captures the extent to which individuals endorse the masculine dimension of honor ideology.
Using a 9-point scale (1 = strongly disagree, 9 = strongly agree), respondents indicate the extent
to which they agree with statements derived from the honor literature, such as “A real man
doesn’t let other people push him around,” and “A man has the right to act with physical
aggression toward another man who calls him a coward.”
Personal concerns. Participants completed Vogel, Wade, and Haake’s (2006) 10-item
Self-Stigma of Seeking Help (SSOSH; α = .87), which measures the extent to which individuals
have negative attitudes toward help-seeking for mental health needs, specifically because seeing
a therapist or counselor would be self-threatening. Using a 5-point scale (1 = strongly disagree, 5
= strongly agree), participants were asked to rate their level of agreement with items such as “I
would feel inadequate if I went to a therapist for psychological help,” and “It would make me
feel inferior to ask a therapist for help.” The SSOSH correlates with other stigma measures and
differentiates individuals who actually sought psychological services from those who did not two
HONOR AND STIGMA OF MENTAL HEALTHCARE 11
months after they completed the scale (Vogel et al, 2006). Hereafter, we will simply refer to
scores on the SSOSH as an index of personal concerns.
Social concerns. Participants also completed Komiya, Good, and Sherrod’s (2000) 5-
item Stigma Scale for Receiving Psychological Help (SSRPH; α = .81) and the 6-item stigma
subscale of Britt et al.’s (2008) Perceived Stigma and Barriers to Care for Psychological
Problems (PSBCPP; α = .88) as measures of social concerns. The SSRPH assess the extent to
which individuals perceive psychological help seeking as resulting in public shame or
disapproval. Each response ranges from 0 (strongly disagree) to 3 (strongly agree), with greater
scores indicating greater concerns about public devaluation. Sample items are “People tend to
like less those who are receiving professional psychological help,” and “Is is advisable for a
person to hide from other people that he/she has seen a psychologist.” The perceived stigma
subscale of Britt et al.’s (2008) PSBCPP was designed for use with a college student sample and
has shown good internal reliability in previous research. On this measure, respondents are asked
to indicate the extent to which 6 potential concerns might affect their decision to seek treatment
for a psychological problem. Example items are “It would be too embarrassing,” “It would harm
my reputation,” and “I would be seen as weak.” Because the correlation between scores on these
two measures (the SSRPH and the PSBCPP) was quite high (r = .61), we standardized scores on
the two scales and used their average as an index of social concerns related to help-seeking for
mental health needs.
As covariates, we included the 10-item Rosenberg self-esteem scale (or RSE; Rosenberg,
1965), on which participants rated their level of agreement with global statements of self-worth
such as “On the whole, I am satisfied with myself,” using response scales anchored with
“strongly disagree” (= 1) and “strongly agree” (= 4). We also included the 20-item impression
HONOR AND STIGMA OF MENTAL HEALTHCARE 12
management (IM) subscale of Paulhus’s Balanced Inventory of Socially Desirable Responding
(1991) to control for response bias. Both the RSE and the IM demonstrated good internal
consistencies in the present study (α = .89 and .79, respectively).
Results and Discussion
Bivariate correlations between honor ideology, personal concerns, social concerns, self-
esteem, and impression management were examined separately for men and women. These
correlations are shown in Table 1. With respect to our focal analyses regarding honor ideology
and concerns about mental healthcare, there were no significant differences between men and
women (nor were there any interactions between gender and honor ideology endorsement). Thus,
we combined responses from men and women in our regression analyses, but included gender as
a covariate.
When we regressed personal concerns on the HIM, gender, the RSE, and IM, we found
that honor ideology was a positive and significant predictor of personal concerns, as shown in
Table 2. As hypothesized, people who strongly endorsed honor ideology on the HIM indicated
greater personal concerns about seeking help for mental health needs compared to people who
did not as strongly endorse honor ideology. A similar result occurred when we regressed social
concerns on honor ideology and all covariates: once again, people with high scores on the HIM
indicated greater social concerns about seeking help for mental health needs compared to people
with low scores on the HIM. Thus, with respect to people’s fears that seeking help for mental
health needs indicates personal inadequacy or failure, and with respect to people’s worry that
others would see them as weak or would otherwise devalue them, men and women with high
scores on the HIM indicated more negative attitudes about seeking mental healthcare.
These results demonstrate a direct link between the endorsement of one of the central
HONOR AND STIGMA OF MENTAL HEALTHCARE 13
dimensions of honor ideology and concerns about the utilization of mental healthcare services.
Although a parallel link has been made in prior research with men (e.g., Vogel, Heimerdinger-
Edwards, Hammer, & Hubbard, 2011), this is the first study of which we are aware to show that
women’s endorsement of honor-based norms can likewise predict their attitudes toward seeking
help. This unique finding might be considered somewhat strange from a strictly gender-role
perspective, but when viewed through the lens of culture and cultural ideologies related to honor,
this pattern among women is not strange at all. To the extent that women embrace the tenets of
one of the core dimensions of honor culture—the meaning of “real manhood”—they will also
tend to exhibit the same stigma-based concerns about mental health needs and mental healthcare
that men do who endorse the ideology of the honor syndrome.
Study 2
If honor-related beliefs and values exacerbate the stigmatization of mental health needs
and mental healthcare among individuals, then we might expect to find that regional differences
in honor-culture status are associated with regional differences in the availability of mental
health resources. Study 2 tested this possibility by examining statewide levels of mental health
personnel (specifically, licensed psychiatrists and psychologists), non-federal mental healthcare
organizations, and state mental health authority expenditures. We also tested the possibility that
the predicted lack of investment in mental health resources might simply reflect a broader deficit
in overall healthcare in honor-oriented regions of the US, rather than a deficit that is particular to
the domain of mental health. Such a broader help-seeking deficit seems quite plausible, in light
of the emphasis in honor-culture ideology on personal strength and toughness, and it is worth
knowing whether the predicted deficits in mental healthcare services might be greater than what
could be expected from a more general deficit in healthcare resources.
HONOR AND STIGMA OF MENTAL HEALTHCARE 14
Method
Culture of honor. For state culture-of-honor (CH) status, we coded states using Cohen’s
(1998) dichotomous designation, which categorizes Western and Southern states (census regions
5-9) as CH states, with the exception of Hawaii and Alaska, which, along with all remaining
states, are coded as non-CH states.
Mental health resources. Data related to mental healthcare resources were obtained
primarily from reports provided by the Substance Abuse and Mental Health Services
Administration (SAMHSA), a division of the US Department of Health and Human Services,
and from Mark, Shern, Bagalman, and Cao (2007). The SAMHSA reports (Center for Mental
Health Services, 2006; Substance Abuse and Mental Health Services Administration, 2010), in
turn, were based upon data gathered from a number of federal and non-federal sources, including
the American Medical Association and the American Psychological Association (for statewide
rates of licensed, clinically trained mental health practitioners), the National Association of State
Mental Health Program Directors (for state mental health expenditures), and SAMHSA’s own
surveys of state mental health services and needs (e.g., SAMHSA’s National Survey on Drug
Use and Health). The data spanned the years 2000 to 2006, and for practitioner data, we were
able to aggregate statewide levels across multiple years of available data to improve reliability.
Practitioner data reflected the number of clinically active psychiatrists per 100,000 state
residents (for the years 2004 and 2006), and the number of licensed, clinically trained
psychologists per 100,000 state residents (for the years 2000 and 2006). State mental health
expenditures per capita were based on money allocated in 2006 to State Mental Health Authority
offices, based on data from the 2006 state budget report of the National Association of State
Budget Officers (http://www.nasbo.org/publications-data/state-expenditure-report/archives). We
HONOR AND STIGMA OF MENTAL HEALTHCARE 15
also calculated the percentage of the total state budget that these State Mental Health Authority
dollars represented. Finally, the number of non-federal mental health organizations per million
state residents was from the year 2002, the most recent estimate available.
General healthcare resources. To examine the possibility that the predicted deficit in
mental healthcare resources among honor states might reflect a broader deficit in overall
healthcare or help-seeking, we also gathered statewide data on the number of primary care
physicians per capita (in 2006) from the American Medical Association’s Physician Masterfile
(2006), and the number of non-psychiatric community hospitals per capita (in 2006) from the US
Census Bureau.
Control variables. We included a number of control variables in our analyses, consistent
with previous studies on the culture of honor and regional differences in the US. From the
Census Bureau, we obtained poverty rates, unemployment rates, and median state income for the
year 2004 from the US Census Bureau and the US Bureau of Labor Statistics. As an index of
statewide economic deprivation, we standardized poverty, unemployment rates, and median
income (reverse coded), and computed a mean of the three variables for each state (α = .75). If
poorer states spend less money on mental health services, which seems like a reasonable
possibility, then controlling for this economic deprivation index in our analyses is important for
distinguishing a cultural from an economic influence on regional differences.
In addition to economic deprivation, we obtained data on statewide collectivism levels
using Vandello and Cohen’s (1999) statewide collectivism index, as collectivism might be
confounded with regional differences in the tendency to seek mental health services outside the
family unit. Similarly, we obtained a measure of religiosity for each state by using the percentage
of adults in 2008 who reported attending religious services (church, synagogue, or mosque) at
HONOR AND STIGMA OF MENTAL HEALTHCARE 16
least once a week or almost every week (Gallup, 2010). If religious beliefs and practices
diminish the felt (or acknowledged) need for mental health services, or the normative value
placed on such services, then religiosity could be an influential source of variance in regional
differences in mental healthcare resources. Because states with large numbers of people living in
metropolitan areas might be better able to support expensive mental health services, we
controlled for this potential geographical influence by obtaining estimates of rurality
(specifically, the proportion of the state population living in rural, non-metropolitan areas in the
year 2000) from the US Census Bureau.
Results
Table 3 displays correlations among and descriptive statistics for all of our predictors and
our mental health resource variables. As predicted, zero-order associations were observed
between state honor status and all 3 of our mental healthcare resource indices, but the latter were
also frequently associated with other statewide covariates. Thus, we examined whether state
honor status remained significantly associated with each mental health investment index after
controlling for all statewide covariates. Because of a strong positive skew in the number of
mental health organizations, we performed a square-root transformation on this variable prior to
analysis in order to reduce the influence of extreme data points.
As shown in Table 4, state CH status remained significantly associated with social
investments in mental healthcare resources, even after controlling for other statewide variables.
Table 5 displays covariate-adjusted means across all mental health indices for honor states and
non-honor states. As shown in Table 5, non-honor states consistently invested more in mental
health services than did honor states, with meaningful effect sizes for licensed mental health
practitioners (d = .67), state expenditures (d = .84), and treatment organizations (d = .76).
HONOR AND STIGMA OF MENTAL HEALTHCARE 17
These results are consistent with our hypothesis of a lack of investment in mental
healthcare in honor states deriving from a greater stigmatization of mental health needs, but
perhaps this pattern simply reflects a broader lack of investment in healthcare in honor states that
is not at all unique to the domain of mental health. We tested this possibility by first examining
general healthcare resources that were not specific to the domain of mental health (per-capita
levels of primary care physicians, and non-psychiatric hospitals—each standardized and
averaged for every state) as a function of state CH status and the statewide control variables
described already. This analysis revealed a significant deficit in primary care doctors among
honor states (covariate-adjusted M = 76.9 per 100,000 residents) compared to non-honor states
(covariate-adjusted M = 84.7 per 100,000 residents), F(1, 44) = 4.60, p < .04. We observed a
similar but non-significant trend for the number of non-psychiatric hospitals per capita, which
was slightly lower in honor states (covariate-adjusted M = 0.22 per 100,000 residents) than in
non-honor states (covariate-adjusted M = 0.26 per 100,000 residents), F(1, 44) = 1.43, p =.24.
Thus, the deficit in mental healthcare resources among honor states was partially replicated
outside the realm of mental healthcare.
Given this broader deficit, in a final set of analyses we analyzed the ratio of mental health
practitioners per capita (in 2006) to primary care doctors per capita (also in 2006); the ratio of
mental health organizations per capita (2004) to non-mental health hospitals per capita (in 2004),
and the percent of each state’s total budget allocated specifically to the state mental health
authority (in 2006), all as a function of state CH status. Consistent with the mental healthcare
stigma hypothesis, analyses revealed that honor states had a lower ratio of mental health to
primary care practitioners per capita (M = 0.52) compared to non-honor states (M = 0.64), F(1,
48) = 5.35, p < .03; a lower ratio of mental health organizations to non-mental health hospitals
HONOR AND STIGMA OF MENTAL HEALTHCARE 18
(Ms = 0.80 and 1.10, respectively), F(1, 48) = 3.31, p = .075; and a lower percentage of their
overall state budgets devoted to mental healthcare services (Ms = 1.71% and 2.54%,
respectively), F(1, 48) = 8.24, p < .01. Although the ratio of mental health organizations to non-
mental health hospitals was not significantly lower in honor states than non-honor states, this
particular comparison is extremely conservative, insofar as many of the mental health
organizations were themselves connected to community hospitals, so there is a link between
these two variables that makes them somewhat problematic to contrast with one another.
Discussion
The results of Study 2 show that the stigma of mental healthcare that was connected in
Study 1 to respondents’ honor ideology endorsement appears to translate to regional deficits in
mental healthcare resources. Although these analyses show that honor states have fewer mental
health resources compared to non-honor states, it is at least possible that this pattern occurs not
because of the stigmatization of mental healthcare, but because of some other regional difference
unrelated to honor-culture beliefs and values. We attempted to capture several such potential
confounds with our control variables, and indeed all but our economic covariate appeared to
have an association with at least one type of mental health resource. Furthermore, Study 2
showed that the predicted deficit in mental healthcare resources found in honor states was not
merely due to a broader, more general lack of investment in healthcare, although some evidence
of such a more general lack of healthcare resources was found.
Another potential confound concerns the need for mental health services. Perhaps people
living in honor states simply have less need of such services because they are mentally healthier.
This is a logical possibility, but other evidence makes this interpretation seem implausible. For
instance, as noted already, studies by Osterman and Brown (2011) showed that not only were
HONOR AND STIGMA OF MENTAL HEALTHCARE 19
suicide rates significantly higher in honor states, but so were rates of serious depression.
Osterman and Brown’s findings thus undermine this alternative interpretation of the lack of
mental healthcare resources in honor states. We return to this alternative interpretation in the
next study as well.
Study 3
In Study 3, we turn to an examination of the utilization of mental healthcare services—
specifically, parents’ reported use of such services for their children with emotional and/or
behavioral problems. If honor cultures do uniquely stigmatize mental health needs and mental
health services, then parents in honor states should be reticent to use such services for the needs
of their children, compared to parents from non-honor states. Of course, parents in honor states
might likewise fail to use healthcare services more generally, or to acknowledge that their
children have any mental health needs at all, in which case any failure to use mental health
services could be explained by strategic ignorance or self-protective denial. Furthermore, if the
honor-related stigma is unique to (or especially strongly associated with) mental healthcare,
honor and non-honor states should not show as large a difference in terms of the utilization of
physical health resources. These are possibilities we tested in Study 3 by comparing honor states
to non-honor states in the odds of parental acknowledgment of the mental health needs of
children, and the likelihood of parental usage of mental healthcare versus physical healthcare
services on behalf of their children.
Given the dearth of mental health resources in honor states (see Study 2), parents in these
states might be less likely to use mental healthcare for their children simply because services are
more difficult to access, rather than because of any special reticence deriving from an honor-
based stigma. If so, then the resource deficit we found in Study 2 might be an important reason
HONOR AND STIGMA OF MENTAL HEALTHCARE 20
for any lower rates of utilization that we might observe in the present study. Using the three
mental health resource measures examined in Study 2 (mental health practitioners, state
expenditures, and treatment organizations), we investigated this possibility via a series of
analyses in which these resources served as potential mediators of the association between state
honor status and reported service utilization. Thus, these mediation analyses tested whether
parents in honor states underutilized even what limited resources were available to them, relative
to parents in non-honor states. These analyses further allowed us to pinpoint which, if any, of
these resources might pose the most immediate potential for ameliorating any under-utilization
that we might observe among parents living in honor states.
Our outcome variables (and covariates) in Study 3 were all individual behaviors, whereas
the culture of honor was defined at the state level. Thus, we used Hierarchical Generalized
Linear Modeling (HGLM) to examine their association across these two levels of analysis.
Because previous studies on regional differences in honor-related behaviors have typically found
such differences only among White respondents (e.g., Barnes, Brown & Tamborski, 2012;
Nisbett & Cohen, 1996), we limited our analyses in Study 3 to this demographic group as well.
Method
Parental utilization of mental health services on behalf of their children was obtained
from survey results from the CDC’s National Health Interview Survey (National Survey of
Children’s Health, 2007). This large-scale, face-to-face interview uses a national probability
sample with state-level stratification and includes data from 91,642 randomly selected children
(with proxy responses from a knowledgeable adult family member for these children; hereafter,
we shall refer to this adult simply as a “parent”). The present data were obtained from the CDC
for the year 2007 (the year closest to the timeframe associated with our data on the availability of
HONOR AND STIGMA OF MENTAL HEALTHCARE 21
mental health resources). Parents were asked as part of this survey whether the selected child
(aged 2-17) had special healthcare needs resulting from ongoing mental health problems.
Parents’ answer to this question (1 = yes, 0 = no) formed the variable that we labeled need
acknowledgement. In addition, parents were asked whether a child who had an acknowledged
need for mental healthcare or counseling had actually received such care during the last 12
months. Their answers (1 = yes, 0 = no) formed the variable that we labeled mental healthcare
utilization (MHC utilization). The survey question regarding the number of times a child saw a
healthcare provider for preventative medical care, such as a check-up, during the last 12 months
served as the measure we labeled physical healthcare utilization (PHC utilization).
In addition to these measures of need acknowledgment and utilization, we also classified
states according to the same procedure used in Study 2, and we used individual-level covariates
that were conceptually similar to those described in Study 2 when possible (e.g., family-level
poverty rather than statewide economic deprivation, frequency of respondents’ religious service
attendance rather than state average service attendance), as well as several other unique
covariates described below.
In HGLM, two or more levels of analysis are addressed simultaneously in a hierarchically
nested data structure. In the current analyses, we nested the individual-level healthcare variables
within states and performed three separate analyses for each outcome variable. For all analyses,
at the lower of the two levels, we examined the association of our individual-level covariates and
the respective outcome variable, with an eye toward replicating and extending the control
variables used in Study 2. Covariates included the gender of the child (0 = male, 1 = female),
whether the child had active insurance coverage (0 = not insured, 1 = insured), the poverty level
of the child’s household (1 = at or below 100% of the poverty level, to 8 = above 400% of the
HONOR AND STIGMA OF MENTAL HEALTHCARE 22
poverty level), how often the child attended a religious service (0 = never, to 4 = daily), and the
age of the child (in years). We had hoped to include a control variable commensurate with the
statewide rurality variable used in Study 2, but too many of our participants were missing data on
the closest approximation of individual rurality to use this variable in our analyses.1 At the higher
of the two levels of analysis, we included the state-level variable of culture-of-honor (CH) status,
using the same classification procedure used in Study 2. For ease of interpretation, poverty,
religion, and age were mean-centered for each state.
Results
Mental health need acknowledgement. The analysis included 60,838 respondents who
answered the MH need acknowledgement question and other questions relevant to the covariates.
Because this outcome variable was binary, we specified the distribution of the outcome variable
as the Bernoulli distribution. This applies the logit link function, making the analysis a multi-
level logistic regression. When the log-odds of acknowledging the child’s mental health needs
was expressed as ln[pij/(1 - pij)] = ηij, our individual-level (level 1) model was:
ηij = β0j + β1j*(GENDERij) + β2j*(INSURANCEij) + β3j*(RELIGIONij) +
β4j*(POVERTYij) + β5j*(AGEij) (1)
In examining the state-level (level 2) effects, HGLM computes intercepts and slopes for each
state. The intercept for state j was expressed as:
β0j = γ00 + γ01*(HONORj) + u0j (2)
Because we assumed that states’ CH status would not interact with any of the individual-level
covariates to predict need acknowledgement, we let these slopes be freely estimated. The model
when the individual and state levels were combined was expressed as:
ηij = γ00 + γ01*HONORj + γ10*GENDERij + γ20*INSURANCEij + γ30*RELIGIONij +
HONOR AND STIGMA OF MENTAL HEALTHCARE 23
γ40*POVERTYij + γ50*AGEij + u0j + u1j*GENDERij + u2j*INSURANCEij +
u3j*RELIGIONij + u4j*POVERTYij + u5j*AGEij (3)
The intercept γ00 indicated the predicted log-odds of MH need acknowledgement for a
child who is male, without insurance, with state-average religious service attendance, state-
average poverty level, and state-average age. γ01 is the main effect of CH status, indicating the
difference in the mean log-odds of need acknowledgement between honor and non-honor states.
The coefficients γ10 to γ50 express the unique contribution of the covariates to the individuals’
log-odds of need acknowledgement, while controlling for other covariates. u0j to u5j are error
(i.e., random effects). See Table 5 for the summary of the results. All individual-level covariates
predicted the individuals’ log-odds of need acknowledgement at significant levels. At the state
level, however, CH was not a significant predictor, γ01 = .03, t(48) = 0.68, p = .50. Thus, the
acknowledgment of a need for counseling or other form of treatment appears to be present
among parents living in honor states at least as much as it is among parents living in non-honor
states.
Mental healthcare (MHC) utilization. The same model was examined with MHC
utilization as the outcome variable, including responses only from those caregivers who
answered that the child did have a mental health need (N = 4103). At the individual level, only
insurance and age were significant predictors. At the state level, respondents in honor states
showed significantly lower log-odds of utilization compared to respondents in non-honor states,
γ01 = -0.22, t(48) = -2.64, p = .01. The odds of MHC utilization in honor states were 20% lower
than the odds of MHC utilization in non-honor states. Thus, as predicted, children with mental
health needs were less likely to receive counseling or treatment for their needs if they lived in
honor states (see Table 6).
HONOR AND STIGMA OF MENTAL HEALTHCARE 24
The results of Study 2 showed that mental healthcare resources were less available in
honor states, which we have argued is a reflection of the lack of value accorded to mental
healthcare in honor cultures. Is reduced access to resources sufficient to explain the levels of
mental healthcare utilization in the present study? To answer this question, we conducted a series
of mediation analyses in which the mental healthcare resources examined in Study 2 (mental
health practitioners, state expenditures, and treatment organizations) were tested as potential
mediators of the association between state CH status and utilization of care. Across all three
mediation models, none of the three resources was a significant predictor of utilization, although
state CH status remained a significant predictor in 2 of these models (it remained marginally
significant in the model with practitioners, p = .105, which was itself a marginally significant
predictor of utilization, p = .08; without CH status in the model, practitioners was, in fact, a
significant predictor of utilization, γ01 = .005, t(48) = 2.60, p = .01). Thus, simple lack of access
is not fully sufficient to account for regional differences in utilization, although having access to
care is, of course, a necessary requirement for being able to utilize care.
Physical healthcare (PH) utilization. We next examined PHC utilization as the outcome
variable, including only respondents from the previous analysis who indicated that their child
had a MH need. Because PHC utilization was recorded continuously rather than dichotomously,
we no longer applied the logit link function. Due to the positive skew (3.29) of the outcome
variable, we performed a natural log transformation to reduce the skew to a more acceptable
level (0.95). At the individual level, all variables except for religion were significant predictors.
At the state level, culture of honor was not a significant predictor of general healthcare
utilization, γ01 = -0.01, t(48) = -0.27, p = .79.2 Thus, although respondents in honor states who
acknowledged their child’s MH needs were less likely to utilize MHC resources, the same
HONOR AND STIGMA OF MENTAL HEALTHCARE 25
respondents utilized PHC resources to the same degree as did their counterparts in non-honor
states. This supports our hypothesis that the stigma applied to MHC services in honor states is
not simply a special case of a larger avoidance of seeking help for general health needs.
Discussion
Study 3 extended the MH-related personal and social concerns expressed by people with
strong honor values to the realm of actual behavior. This study supports the results of Study 1 by
showing that children in honor states were less likely than their counterparts in non-honor states
to have received MHC services in the previous year. This deficit is particularly noteworthy
because of the fact that their caregivers acknowledged that they had a need for such services.
Furthermore, this under-utilization in honor states was independent of a host of important,
individual-level control variables, including religiosity, poverty, and insurance coverage.
Consistent with the results of Study 1, the regional utilization difference was also independent of
gender, which itself was not a significant predictor of utilization.
Contrary to expectation, we found a non-significant regional difference in need
acknowledgement. We were surprised by this regional equivalence, which contrasts with
previous evidence of a significantly higher rate of serious depression among people living in
honor states (Osterman & Brown, 2011), suggesting a greater need for mental healthcare in these
regions. Thus, the fact that parents’ acknowledgement of their children’s need for mental
healthcare services was not significantly higher in honor states might suggest that parents were
under-reporting their children’s mental health needs in the present study. In effect, the greater
need for mental health care might run counter to a culturally motivated reticence to admit such a
need (which might be seen as a sign of weakness or impurity, consistent with the results of Study
1). These two factors might then cancel each other out, resulting in no difference in need
HONOR AND STIGMA OF MENTAL HEALTHCARE 26
acknowledgement. Of course, this explanation is purely speculative and will require more direct
evidence before we can infer that such opposing factors can account for this null finding.
In view of the deficit in MHC resources shown in Study 2, we attempted to determine
whether these resource deficits are sufficient to explain the under-utilization we discovered in
Study 3. The results pertaining to this question were mixed, however. Among the three MHC
resources examined in Study 2, only the practitioners variable reduced state CH status to non-
significance. This finding might suggest that increasing the number of MH practitioners could
prove to be an especially important avenue for ameliorating the under-utilization of MH services
that we observed in honor states. However, the practitioners variable, like expenditures and
organizations, was not itself a significant predictor of utilization in the mediation model, so the
requirements for a valid mediator were not fully met. Thus, simple lack of access to mental
health resources does not appear to be fully sufficient to explain the under-utilization of MHC
resources by parents living in honor states. This lack of mediation is somewhat disconcerting, as
it indicates that although the lack of resources for mental healthcare in honor states is indeed a
problem, solving this problem might not be sufficient to combat the additional problem of under-
utilization of mental healthcare services for children needing care. Although it is imperative that
people have access to proper resources to meet their mental health needs, simply having access is
not enough—people must also be willing to avail themselves of those resources. The data from
Study 2 and Study 3 together suggest that both lack of availability and underutilization of
available options are serious issues connected to the values and priorities of honor culture.
General Discussion
Among the many dimensions on which cultures vary is the extent to which a society
places defense of reputation at the core of its value system. This emphasis reflects the essence of
HONOR AND STIGMA OF MENTAL HEALTHCARE 27
the honor syndrome, and cultures or subcultures characterized by this syndrome exhibit reliably
higher rates of interpersonal aggression, at least when such aggression serves a reputation-
management function (Nisbett, 1993). Recent studies by Osterman and Brown (2011) have
extended this connection between honor and violence against others to the realm of suicide,
showing that men and women living in honor states in the US South and West evidence
heightened rates of suicide (especially if they are White and live in small towns, where
reputation concerns ought to be greatest). This research also provided preliminary evidence of a
reticence to seek help for mental health needs in honor states, despite a greater level of need (in
the form of higher rates of serious depression).
The present set of studies investigated more directly this inference about the reticence to
seek help for mental health needs among individuals (Study 1) and in regions (Study 2 and 3)
heavily influenced by honor-culture norms. Study 1 demonstrated that respondents who strongly
embraced honor-related beliefs and values more strongly expressed concerns about the use of
mental health services, and these concerns revolved around the fear of being (and being seen) as
weak, inadequate, and unlikable. This association was independent of respondents’ levels of self-
esteem, tendency to respond in socially desirable ways, or gender. This last finding is noteworthy
in part because the measure of honor ideology that we used in Study 1 was focused on the
masculine dimension of honor ideology.
Study 2 switched to a regional level of analysis and showed that honor states in the US
invested less in mental healthcare resources compared to non-honor states. This difference
remained when we controlled statistically for a host of potential regional confounds, including
economic deprivation, rurality, and religiosity. Study 3 showed that although caregivers in honor
states were willing to acknowledge their child’s need for mental healthcare, they were less likely
HONOR AND STIGMA OF MENTAL HEALTHCARE 28
to seek professional help for those needs, compared to parents in honor states. This regional
difference also remained when we controlled for individual differences in other, non-honor
variables, such as religiosity, poverty, and health insurance. Importantly, this difference was not
replicated when we examined caregivers’ use of physical healthcare services. Finally, we found
that the availability of mental healthcare resources could not fully account for the regional
differences in utilization, although a noteworthy trend in this regard was observed for MH
practitioners. This pattern suggests that merely increasing access to resources might not be
sufficient by itself to reduce the under-utilization of such services in honor states, as a culturally-
based reluctance to use available services might still remain even when access is improved.
Thus, both increased access to care and reduction of the social stigma associated with the use of
care are crucial if we want to increase help-seeking behaviors.
These studies represent a novel implication of honor culture beliefs and values that has
previously not been demonstrated, although a similar reluctance to use mental healthcare
services has been documented among various US minority groups that tend to exhibit honor and
“face” related ideologies, such as East Asians (e.g., Loya, Reddy, & Hinshaw, 2010). The
present studies, of course, are not without important limitations. For instance, Studies 2 and 3
depended on a regional level of analysis, and such analyses are fraught with interpretational
difficulties. Although we relied on classic distinctions between “honor states” and “non-honor
states” in these two studies (e.g., Cohen, 1998) and controlled for a number of potential
confounds (e.g., poverty, religiosity), we cannot be sure that we controlled for all of the “right”
potential confounds in our analyses. This problem is equally true of prior studies of honor culture
and aggression that rely on a regional level of analysis (e.g., Brown et al., 2009; Nisbett, 1993),
which is why it is so important that these studies are complemented by other investigations that
HONOR AND STIGMA OF MENTAL HEALTHCARE 29
use an individual level of analysis (e.g., Cohen et al., 1996), as well as more direct measures of
honor-related beliefs and values (e.g., Barnes et al., 2012; Leung & Cohen, 2011). The
association we found in Study 1 between individuals’ honor ideology endorsement and their
attitudes toward using mental health services goes a long way toward reducing the
interpretational difficulties inherent in regional comparisons, but we cannot eliminate these
difficulties entirely.
Despite these limitations, we believe that these studies represent an important first step in
demonstrating the link between the cultural ideology of honor and the stigmatization of mental
health services, and we hope they inspire additional research in this area. Such research could
occur at a more “macro” level in comparisons of nations that differ with respect to the extent to
which they are characterized by honor values, and at a more “micro” level in studies that use
more subtle measures of honor ideology endorsement, including non-conscious ones (e.g., Imura,
et al., 2013), as well as more subtle measures of mental healthcare stigma.
These studies also underscore the perniciousness of the honor syndrome with respect to
mental health. Previous research demonstrates the myriad ways in which honor ideology can
transform trivial altercations into homicides (Nisbett & Cohen, 1996). This transformation
appears not only among adults, but also the young (Brown et al., 2009). The ideology that
magnifies the emotional consequences of honor threats also appears capable of turning shame
and distress into suicidal impulses (Osterman & Brown, 2011). Thus, when other people threaten
someone’s honor in an honor culture, those perpetrators are often targeted for retaliation. When
someone’s own failings threaten honor, however, violent impulses might be directed inwardly.
What is particularly destructive about this cultural syndrome, though, is that it appears to
stigmatize help-seeking for feelings of emotional distress. According to the present studies, even
HONOR AND STIGMA OF MENTAL HEALTHCARE 30
if people overcome their cultural aversion to help-seeking, the resources needed to help them—
from mental health practitioners to hospitals—may be absent. Changing this cultural
stigmatization remains an enormous challenge for policy makers interested in addressing our
nation’s mental health needs.
HONOR AND STIGMA OF MENTAL HEALTHCARE 31
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Footnotes
1 The dataset included a variable indicating whether or not respondents lived in a
metropolitan statistical area. More than 33% of respondents were missing data for this variable.
Moreover, these missing data resulted in 15 states being eliminated from level 2 of our HGLM
analyses. When we included this covariate despite these problems, this geographic variable was
not a significant predictor of our DVs.
2 Although the natural log transformation of the outcome variable reduced the skew to an
acceptable level, we were still concerned with the skew. We thus recoded this variable as 0 =
have seen a healthcare provider zero or one time, and 1 = have seen a healthcare provider two
or more times. In an analysis using this recoded variable, states’ CH status still was not a
significant predictor of utilization of PH services, γ01 = 0.07, t(48) = 0.79, p = .43.
HONOR AND STIGMA OF MENTAL HEALTHCARE 38
Table 1
Zero-order Correlations Among and Descriptive Statistics for All Variables Used in Study 1
**p .01, *p .05
Note. Intercorrelations for females (n = 378) are presented above the diagonal, and
intercorrelations for males (n = 185) are presented below the diagonal. Means and standard
deviations for males are presented in the vertical columns, and means and standard deviations for
females are presented in the horizontal rows. HIM = honor ideology for manhood scale; Personal
concerns = self-stigma of seeking help scale; Social concerns = stigma scale for receiving
psychological help and perceived stigma and barriers to care for psychological problems; Self-
esteem = Rosenberg self-esteem scale; Impression management = Paulhus’s balanced inventory
of socially desirable responding, impression management subscale.
1
2
3
4
5
MF
SDF
1.
HIM
.17**
.23**
.03
.20**
4.59
1.56
2.
Personal concerns
.19**
.67**
.26**
.10
2.54
0.84
3.
Social concerns
.25**
.71**
.24**
.15**
–0.04
0.89
4.
Self-esteem
.01
.10
.15*
.18**
31.78
6.00
5.
Impression
management
.24**
.21**
.21**
.33**
3.03
0.84
MM
5.67
2.66
0.07
32.98
2.97
SDM
1.53
0.78
0.90
5.36
0.78
HONOR AND STIGMA OF MENTAL HEALTHCARE 39
Table 2
Multiple Regression Analyses Predicting Personal and Social Concerns Associated with Mental
Healthcare (Study 1)
Personal Concerns
Social Concerns
β
t
β
t
HIM scores
.19
3.99**
.23
5.38**
Gender
.03
0.75
.001
0.03
Self-esteem
–.20
–4.79**
–.20
–4.85**
Impression
Management
–.05
–1.24
–.08
–1.91
** p .01
HONOR AND STIGMA OF MENTAL HEALTHCARE 40
Table 3
Descriptive Statistics for and Correlations among Primary Variables in Study 2
1
2
3
4
5
6
7
8
1.
Culture of honor
2.
MHC practitioners
.40**
3.
State MHC
expenditures
.44**
.48**
4.
MHC organizations
.45**
.14
.43**
5.
Economic deprivation
.39**
.42**
.24**
.27
6.
Collectivism
.20
–.02
–.06
.38**
.09
7.
Religion
.35**
.57**
.56**
.36**
.52**
.31*
8.
Rurality
.01
.44**
.11
.31*
.27
.27
.23
M
0.54
0.00
105.65
4.10
0.00
50.08
41.06
0.28
SD
0.50
0.91
62.27
0.98
0.82
11.34
8.81
0.15
Note. Culture of honor = state culture of honor status; honor states are coded as 1 and non-honor states are coded as 0;
MHC practitioners = the number of clinically active psychiatrists per 100,000 state residents (averaged for the years
2004 and 2006), and the number of clinically trained (PhD level) psychologists per 100,000 state residents (averaged
for the years 2000 and 2006); State MHC expenditures = state mental health expenditures per capita from state
budgets for the year 2006; MHC organizations = the number of non-federal mental health organizations per million
state residents from the year 2002 (square-root transformed); Economic deprivation = includes poverty rates,
unemployment rates, and median state income (2004); Collectivism = Vandello and Cohen’s (1999) statewide
collectivism index; Religion = the percentage of adults in 2008 who reported attending religious services (church,
synagogue, or mosque) “at least once a week” or “almost every week” (Gallup, 2010); Rurality = the proportion of
the state population living in rural, non-metropolitan areas in 2000.
* p .05, ** p .01
HONOR AND STIGMA OF MENTAL HEALTHCARE 41
Table 4
Multiple Regression Analyses Predicting Mental Healthcare Resources in Study 2
MHC Practitioners
State MHC
Expenditures
MHC
Organizations
β
t
β
t
β
t
Culture of honor
.25
2.06*
.31
2.59**
.30
2.34*
Economic deprivation
–.03
–0.23
.11
0.87
.11
0.77
Rurality
.30
2.49*
.33
2.73**
.37
2.82**
Religion
.42
3.00**
.68
5.01**
.25
1.67
Collectivism
.18
1.48
.30
2.26**
.13
1.02
Note. * p .05, ** p .02
HONOR AND STIGMA OF MENTAL HEALTHCARE 42
Table 5
Covariate-adjusted Means for All Mental Healthcare Resources among Honor States and Non-
honor States in Study 2
MHC practitioners
State MHC
expenditures
MHC Organizations
CH
Non-CH
CH
Non-CH
CH
Non-CH
M
42.93
55.96
$88.15
$126.19
3.83
4.41
MSE
336.69
2128.62
0.63
d
0.67
0.84
0.76
Note. MHC practitioners are the number of licensed psychologists and psychiatrists and are per
100,000 state residents; State MHC expenditures are simple per capita rates; MHC organizations
are per million state residents and are square-root transformed to reduce positive skew.
HONOR AND STIGMA OF MENTAL HEALTHCARE 43
Table 6
HGLM Results for Study 3
Need Acknowledgement
MHC Utilization
PHC
Utilization
Effects
Coefficient
Odds Ratio
Coefficient
Odds Ratio
Coefficient
Individual-level variables
Gender
0.46**
0.63 (.39)
0.03
1.03 (.51)
0.04*
Insurance
0.55**
1.73 (.63)
0.59**
1.81 (.64)
0.17**
Religion
0.16**
0.85
0.02
1.02
0.01
Poverty
0.18**
0.84
0.02
1.03
0.02**
Age
0.09**
1.09
0.08**
1.09
0.02**
State-level variables
Intercept
3.11**
0.04
0.35*
1.42
0.84**
CH Status
0.03
1.03 (.51)
0.22**
0.80 (.44)
0.01
*p .05, **p .01
Note. Gender is coded as 0 = male and 1 = female. Insurance is coded as 0 = not insured and 1 =
insured. State honor status is coded as 0 = non-honor states, 1 = honor states. The probabilities
are presented in parentheses for dichotomous variables. Because PHC utilization was a
continuous rather than a dichotomous variable, only regression coefficients are presented.
