ORIGINAL PAPER

Stigma and discrimination toward mental illness: translationand validation of the Italian version of the attributionquestionnaire-27 (AQ-27-I)

Luca Pingani • Matilde Forghieri • Silvia Ferrari • Dror Ben-Zeev • Paolo Artoni •

Fausto Mazzi • Gaspare Palmieri • Marco Rigatelli • Patrick W. Corrigan

Received: 9 August 2010 / Accepted: 30 May 2011 / Published online: 19 June 2011

� Springer-Verlag 2011

Abstract

Purpose The aim of this study was to translate the

Attribution Questionnaire-27 (AQ-27) to the Italian lan-

guage (AQ-27-I), and to examine the reliability and

validity of this new Italian version.

Methods The questionnaire was translated using the

standard translation/back-translation method. Cronbach’s

alpha and intraclass coefficients were used to estimate

instrument reliability. Confirmatory factor analysis was

conducted to corroborate the original English version

factor structure in the new measure, and to establish

validity. Path analyses were meant to validate relationships

found in the English version among Italian-speaking

participants.

Results The AQ-27-I demonstrated acceptable internal

consistency, with a Cronbach’s alpha of 0.82 for the total

scale and ranging between 0.52 and 0.91 for the subscales.

The test–retest reliability was also satisfactory, with

intraclass correlation coefficients of 0.72 for the total scale

and ranging between 0.51 and 0.89 for the subscales. Fit

indices of the model supported the factor structure and

paths.

Conclusions The AQ-27-I is a reliable measure to assess

stigmatizing attitudes in Italian.

Keywords Psychometrics � Reliability and validity �Stereotyping � Questionnaires � Factor analysis

Introduction

People suffering from mental illness are more severely

stigmatized than those with other medical conditions, often

resulting in negative social, political, economic and psy-

chological outcomes [1–3]. Members of the general public

are less likely to interact with persons with mental illness

[4]. Stigmatizing attitudes contribute to discriminating

practices in everyday life situations, restricting private and

public institution opportunities. For fear of stigmatization,

individuals with mental illness may disengage from soci-

ety, resulting in worsening of their clinical conditions and

prognosis [5–7].

Stigmatization can be conceptualized as a process that

entails complex cognitive–behavioral interactions between

the individual and the social environment [8]. There are

L. Pingani (&)

Department of Psychiatry, International Doctorate School

in Clinical and Experimental Medicine,

University of Modena and Reggio Emilia,

Policlinico di Modena, 71 Via del Pozzo,

41124 Modena, MO, Italy

e-mail: trp@unimo.it

M. Forghieri � S. Ferrari � P. Artoni � F. Mazzi � M. Rigatelli

Department of Psychiatry, University of Modena and Reggio

Emilia, Policlinico di Modena, 71 Via del Pozzo,

41124 Modena, MO, Italy

D. Ben-Zeev

Dartmouth Psychiatric Research Center,

Dartmouth Medical School, Rivermill Commercial Center,

85 Mechanic Street, Lebanon, NH 03766, USA

D. Ben-Zeev

Thresholds Research Institute,

4101 N. Ravenswood Ave, Chicago, IL 60613, USA

G. Palmieri

Villa Igea Hospital, 73 Strada Stradella,

41126 Modena, MO, Italy

P. W. Corrigan

Institute of Psychology, Illinois Institute of Technology,

3424 S. State Street, Chicago, IL 60616, USA

123

Soc Psychiatry Psychiatr Epidemiol (2012) 47:993–999

DOI 10.1007/s00127-011-0407-3

two leading theoretical explanatory models of stigmatiza-

tion: Corrigan et al. [9] conceptualize public stigma as the

status loss and discrimination triggered by negative preju-

dices toward people with mental illness by those around

them. Link and Phelan [10] focus on self-stigma and con-

ceptualize it as the reactions of individuals who belong to a

stigmatized group when facing the stigmatizing attitudes

they apply against themselves. Stereotypes, prejudice and

discrimination are the cognitive, emotional and behavioral

components of the two models: stereotypes are negative

beliefs, addressed to other for public stigma (e.g. danger-

ousness or incompetence), or to self for self-stigma (belief

of being incompetent); stereotypes activate the emergence

of prejudice as their cognitive and emotional response (fear

or anger for public stigma, low self-esteem for self-stigma),

subsequently leading to the behavioral reaction of dis-

crimination (e.g. avoidance or withholding employment

and housing opportunities for public stigma; fails to pursue

work for self-stigma) [11]. Two further concepts are

described in the context of the public stigma model, those

of responsibility and dangerousness. The first is based on

Weiner’s attribution theory [12]: if the patient is deemed

responsible for his/her disorder, then people may be angry

with him/her, and will not provide assistance; if instead the

patient is considered a victim of the disorder, then he/she

will evoke feelings of pity and readiness to help. According

to the theory of dangerousness [13, 14], those who perceive

psychiatric patients as dangerous will fear and subse-

quently avoid them. Examples of stigmatization typically

include less job opportunities and social exclusion or bul-

lying. Stigma often emerges in the context of mental ill-

nesses, particularly schizophrenia [15], due to its disruptive

effects on behaviour and functioning, the side effects of

antipsychotic medications used to treat it, and uncertainties

as to its etiology and trajectory [16, 17].

The need to overcome stigma stimulated the creation of

a number of public health programmes in different coun-

tries, such as the Changing Mind Campaign by The Royal

College of Psychiatrists in the UK [18], the Psyke Cam-

paign in Sweden [19], the National Mental Health Charity

SANE in Australia [20], and the World Psychiatric Asso-

ciation’s Global Programme Against Stigma and Discrim-

ination because of Schizophrenia [21, 22]. Moreover,

elimination of stigma associated with mental illness was

identified as one of the central goals in public health by the

World Health Organization, at the European Ministerial

Conference on Mental Health in Helsinki in 2005 [23, 24].

Importantly, previous studies have shown that beliefs,

expectations, and attitudes about behavioural disturbances

predict stigma more than a strictly biomedical conceptu-

alization of schizophrenia [25], and that effective anti-stigma

campaigns should focus on these elements, following a

multidimensional, target-tailored approach [26].

Over the last few decades, Italy has made substantial

strides in improving public awareness and understanding of

mental illness. A number of examples include a 1978 de-

institutionalization directive outlined in law 180 leading to

gradual replacement of mental hospitals with community-

based psychiatric health care organizations, exclusion of

‘‘dangerousness to self and to other’’ as criteria for com-

pulsory mental health hospital admission, and creation of

advocacy groups such as the Italian Association Against

Stigma in 2003 [27]. However, much work in de-stigma-

tizing mental illness in Italy remains to be done. Increase of

interest on this subject in the general public and the media

has been recently witnessed by the release of movies and

TV-series dedicated to mental disorders, the history of the

Italian psychiatric reform and the work initiated by Franco

Basaglia, though the contribution to de-stigmatization of

these initiatives is controversial. Magliano et al. [28]

examined beliefs on causes, treatments, and consequences

of mental illness among 1,888 subjects including lay peo-

ple, mental health professionals, and relatives of patients

with schizophrenia across Italy, by means of a self-reported

questionnaire; the findings suggested a need to improve

information made available to the general public on what

schizophrenia is, how it is treated, and its causative role in

dangerous behaviours [28, 29].

At present, there are two instruments measuring stigma-

tization in the Italian language: ‘‘The Community Attitudes

to The Mentally Ill III’’ [30] is a questionnaire consisting of

40 statements concerning the acceptability of mental health

services and patients with mental disorders in the commu-

nity. Factor analysis of this measure detected three relatively

independent factors: physical distance and fear, social dis-

tance and isolation, and social responsibility and tolerance

(but Cronbach’s alpha values are unknown). The Ques-

tionnaire on the Opinions about Mental Illness (QO) [31] is a

self-reported instrument that assesses beliefs about: the

causes of schizophrenia, the effectiveness of available

treatments for this disorder, the political, social and affective

rights of the patients with schizophrenia, and their ability to

perform social and occupational roles; QO test–retest reli-

ability ranged from 0.50 to 1 for 74% of the items (Cohen’s

kappa coefficient), while Cronbach’s alpha coefficient ran-

ged between 0.56 and 0.66 (family version) and between

0.42 and 0.72 (professional version).Unfortunately, these

two existing questionnaires are not appropriate measures for

elements of the stigmatization process; moreover, the QO

was not designed to be used in the general population, but

only among relatives of psychiatric patients.

Therefore, despite these efforts, evidence and data on

stigma, its psycho-social correlates and outcomes of

stigma-reducing public campaigns in Italy are still few and

sparse and appropriate measures for the assessment of

stigma and stigmatization processes need to be developed.

994 Soc Psychiatry Psychiatr Epidemiol (2012) 47:993–999

123

The current study focuses on measurement of public

stigma. Several measures have been developed to evaluate

public attitudes toward mental illness [16, 32–35]. Among

them, the Attribution Questionnaire-27 (AQ-27) [36] con-

stitutes a feasible and effective self-administered measure,

designed to explain attitudes, affect, and behavioural

intentions related to a hypothetical person suffering from

mental illness. AQ-27 is based on the two explanatory

stigma models previously described: the attribution theory

[37] and Link’s theory concerning dangerousness [38]. The

two pathway models have shown to relate to each other

[39], leading to an integrated definition of stigma.

Acknowledging the lack of a reliable instrument mea-

suring stigma in Italian language, and existing evidence for

reliability of the original English version of AQ-27, the aim

of the current study was to examine the reliability and

validity of the AQ-27 translated into Italian language (AQ-

27-I). Factor structure will be confirmed on the Italian

sample, as will conceptual paths.

Methods

Instrument description

The AQ-27 was tailored as a 27-brief statement questionnaire

about an imaginary patient called ‘‘Harry’’, a 30-year-old

single man with schizophrenia. Individuals who complete

the measure are asked to rate how much they agree with

each statement made about ‘‘Harry’’ on a Likert scale from

1 (not at all) to 9 (very much). Two previous confirmatory

factor analyses were used to develop a measurement model

that demonstrates an acceptable fit to the data and provide

psychometric efficacy to the questionnaire [36, 40].

Measure translation

The translation of the original version of AQ-27 was a

three-step process. In the first step, three native Italian

speakers, bilingual in English, independently translated the

original instrument into Italian. A collaborative pooled

version of the questionnaire was then obtained from the

three translations. In the second step, the pooled version was

back-translated into English by a professional translator. A

draft Italian version of the instrument for student testing

was obtained from the comparison between the original

questionnaire and the back-translation. The third and final

step consisted of testing the draft Italian version on 30

Italian-speaking students (as many males and females) from

the University of Modena and Reggio Emilia, at group

meetings conducted by the authors; at the meetings, every

item was read out aloud (with participants also following

the text on paper-printed copies) and a group discussion

followed, with students required to answer two questions

for each items: ‘‘What does this statement mean to you?’’

and ‘‘Is there any other wording that enables this meaning to

be expressed more clearly?’’. The face validity of the

questionnaire was not tested by quantitative methods, but

through the group discussion just described. Answers were

subsequently analysed by the authors (LP, SF and MF),

leading to the final Italian version of the AQ-27 (AQ-27-I),

whose psychometric properties were then tested.

Sample

An opportunistic sample of relatives of students from

Modena and Reggio Emilia University was collected.

Students were asked to contact and have the questionnaire

filled in by five of their relatives at their choice. Inclusion

criteria were: (1) being aged over 18; (2) not having a first-

and second-degree relative suffering from a well-defined

mental illness. Of the 225 subjects contacted, only 11

(4.89%) did not respond or completed the questionnaire,

providing a final sample of 214 subjects.

Statistical analysis

The Statistical Package Social Sciences (SPSS) version

13.0 and Amos version 18.0 were used for data analysis.

Cronbach’s alpha was used to estimate instrument reli-

ability. Confirmatory factor analysis was used to corrobo-

rate that the factor structure of AQ-27-I was the same as the

one identified for the original version: path analysis is an

extension of the regression model, used to test the fit of the

correlation matrix against two or more causal models. The

model is usually depicted in a circle-and-arrow figure in

which single-headed arrows indicate causation.

Model fitness was assessed using the following indices of

fit: v2, goodness of fit index (GFI [ 0.90), root mean square

error of approximation (RMSEA \ 0.10) and adjusted

goodness of fit index (AGFI [ 0.90). The same indices

were also combined with beta’s to test the path model. The

test–retest reproducibility was evaluated using the intraclass

correlation coefficient (ICC), and the value of 0.65 was

accepted as adequate reliability for a group of patients.

Results

Socio-demographic characteristics

Table 1 summarizes the socio-demographic characteristics

of the participants. Age of the sample ranged from 18 to

89 years (mean = 40.15, SD = 16.36). The participants

were equally distributed for gender, 82.7% had at least a

high school education (50.5% attended high school and

Soc Psychiatry Psychiatr Epidemiol (2012) 47:993–999 995

123

26.6% university); 9.32% of the sample belonged to the

health professional group (psychiatrists, residents in psy-

chiatry, graduate nurses and psychologists), 18.69% were

students, and the remaining population were included into

the ‘‘other profession’’ group (including unemployed,

employed, housewives, and pensioners).

Confirmatory factor analysis

The relationship related to attributions of personal

responsibility for mental illness is provided in Fig. 1. As

described in Weiner’s attribution theory [37], the 12 items

were defined as loading in six different first order latent

factors: Personal Responsibility (10, 11, 23), Pity (9, 22,

27), Help (8, 20, 21), Anger (1, 4, 12), Coercion (5, 14, 25)

and Segregation (6, 15, 17). Fit estimates partly supported

the findings, although v2 (120) = 233.927 (P \ 0.001)

does not support fit the v2/df ratio = 1.95. The GFI =

0.893 and AGFI = 0.848 are both little below criterion

levels. RMSEA on the other hand was satisfying (0.09).

We decided against dropping out items and redoing the

structural equations for two reasons. Our major goal was

to determine whether the Italian model mirrored the

Table 1 Socio-demographic characteristics of the sample (n = 214)

Variable Frequency (n) Percentage (%)

Gender

Male 102 47.7

Female 112 52.3

Educational level

No education 1 0.5

Elementary school 11 5.1

Intermediate school 37 17.3

High school 108 50.5

University degree 57 26.6

Employment

Unemployed 2 0.9

Student 40 18.7

Employed 118 55.2

Housewife 10 4.7

Pensioner 24 11.2

Psychiatrist 5 2.3

Resident in psychiatry 6 2.8

Graduate nurse 8 3.7

Psychologist 1 0.5

.06 p=.48

1.42*** 1.85*** 1.56***

.93***

.51***

1.61*** .97*** .77*** .47***

1.75*** 1.68*** 1.65*** .75*** 2.26*** 2.27***

PERSONAL RESPONSIBILITY

PITY HELP

AQ9 AQ22 AQ27 AQ8 AQ20 AQ21

ANGER

COERCION

AQ5 AQ14 AQ25

SEGREGATION

AQ6 AQ15 AQ17

AQ11 AQ23

.75*** .03 p=.70

.43***

.78***

AQ10

.53*** .22*** .78***

AQ1 AQ4 AQ12

Fig. 1 The six-factor measurement of the responsibility model (***P \ 0.001)

996 Soc Psychiatry Psychiatr Epidemiol (2012) 47:993–999

123

American; these fit indicators are equivalent on the matter.

Secondly, each of the AQ items loaded significantly into

the corresponding latent factor. Hence, there was no clear

choice about development of subsequent structural equa-

tions. Correlations between factors are much more robust,

however. These are provided in the figure. The model

representing attribution and pity was not significantly

associated. However, betas for attribution, anger, coercion

and segregation were large, ranging from 0.22 to 2.27.

Indices for the path model representing the theory of

dangerousness [13, 14] are presented in Fig. 2. According

to this theory, the nine factors were defined as loading in

three different first order latent factors: Dangerousness

(2,13,18), Fear (3,19,24) and Avoidance (7,16,26). Chi

square did not support fit [v2 (24) = 85.384 (P \ 0.001),

v2/df ratio = 3.56]. However, the GFI = 0.919 and

RMSEA = 0.109 met criteria; AGFI = 0.848 is only a

little below criterion level. All the AQ items loaded sig-

nificantly into corresponding factors. Correlations between

factors were very large, ranging from 0.50 to 0.84.

Internal consistency and test–retest reliability

Internal consistency reliability for the AQ-27-I as a whole

was 0.818. Cronbach’s alpha coefficients for each factor

are displayed in Table 2. Satisfactory reproducibility was

indicated by the acceptable test–retest reliability, measured

as intraclass coefficient, whose total value was 0.82.

Intraclass coefficients for each factor are also displayed in

Table 2.

Discussion

As awareness of the clinical significance of stigma in

mental health grows, so does the need for valid and reliable

instruments to measure the phenomenon, from the patient,

general public, and helping professional’s perspective. The

aim of this study was to translate and examine the reli-

ability and validity of the Italian version of the AQ-27

(AQ-27-I). To our knowledge only one previous study has

ever examined stigmatizing attitudes toward mentally ill

patients in Italy using a standardized, validated Italian

questionnaire [28, 29].

The AQ-27-I, in its original English version, follows

well-articulated theoretical constructs, considering

responsibility and dangerousness factors and their influence

on stigma severity. Moreover, by changing the initial

vignette presentation depicting ‘‘Harry’’, it allows adapta-

tion to specific aspects, such as familiarity and presence of

violent behaviour, to explore their secondary contribution

to stigmatizing attitudes [36].

To validate the AQ-27-I, confirmatory factor analyses

and path analyses were carried out. General fit indices were

equivocal though individual AQ items loaded significantly

into corresponding latent factors [36, 40–42]. Betas

1.76*** 1.30*** 1.31*** 1.69*** 1.82*** 1.75***

1.21*** 1.52***

.84*** DANGEROUSNESS

FEAR AVOIDANCE

1.49***

AQ3 AQ19 AQ24 AQ7 AQ16 AQ26

.50***

AQ2 AQ13 AQ18

Fig. 2 The three-factor measurement of the dangerousness model (***P \ 0.001)

Table 2 Internal consistency and test–retest reliability

AQ-27-I Internal consistency

reliability (Cronbach’s

alpha coefficient)

Test–retest

reliability (intraclass

coefficient)

Responsibility 0.615 0.68

Pity 0.676 0.65

Anger 0.521 0.51

Dangerousness 0.755 0.72

Fear 0.912 0.89

Help 0.814 0.80

Coercion 0.570 0.53

Segregation 0.801 0.78

Avoidance 0.570 0.54

Total 0.818 0.72

Soc Psychiatry Psychiatr Epidemiol (2012) 47:993–999 997

123

representing relationships among factors mostly paralleled

findings from studies conducted with the English version. In

terms of the attribution model, attributing blame led to anger

which increased endorsement of coercion and segregation.

In the second path model, dangerousness hugely predicted

fear which, in turn, was associated with avoidance.

The overall Cronbach a values for AQ 27-I were highly

acceptable, indicating satisfactory internal consistency of

the instrument. Regarding stability of the instrument, the

test–retest reliability of the scores was also highly

acceptable, with ICC scores for the total scale and sub-

scales exceeding 0.65 (excepted for Anger, Coercion and

Avoidance).

There are several limitations to be addressed, partially

cautioning generalizability of our findings. Firstly, Cron-

bach’s a coefficient limited values in Responsibility,

Anger, Coercion and Avoidance factors suggest that other,

less well identified variables could have an important role

in the variance left. Secondly, the questionnaire has been

tested on an opportunistic sample, which might not be fully

representative of the Italian population. Nevertheless,

comparing socio-demographic features of our sample with

2008 national statistics [43], no differences were found in

mean age and male/female ratio; the level of school edu-

cation was higher in the study sample than the national

average: this limits generalizability of findings due to the

well-known impact of educational level on stigma and it is

possible that stronger stigmatizing attitudes would be seen

in a less educated sample. Finally, it is possible that dif-

ferences in cultural background and history of psychiatric

care between Italy and the US, where the original version

of the questionnaire was developed, might require a more

tailored set of questions closely related to the Italian cul-

tural context. The deeply rooted community-based tradition

of psychiatric health care in Italy might have contributed to

a higher level of tolerance and acceptance toward psychi-

atric patients, with strong emotional, ideological and

political forces driving away from the previous institutional

model. On the other hand, it has been suggested that new

and more subtle discriminating behaviours might have

arisen by the integration of mentally ill patients in the

society [44, 45]. These new potentially stigmatizing atti-

tudes remain to be explored and require further examina-

tion on larger and more representative key-populations,

also further contributing to the validation of AQ-27. The

availability of a valid Italian version could allow more

culturally specific research, in larger and more various

clinical settings, hopefully providing cross-cultural com-

parisons and examining whether the unique community-

based treatment tradition in Italy results in different public

attitudes toward psychiatric patients [41, 42].

Our study aimed at translating and validating the Italian

version of AQ-27, a popular and operationalized

instrument designed to explore stigma in psychiatry. Its

availability for use in different settings (i.e. General Hos-

pital, Primary Care, and Mental Health Services) and its

adaptability to different clinical scenarios or respondents

might help elucidate the complex and still poorly docu-

mented phenomenon of stigma in mental illness.

Conflict of interest All authors declare that there are no financing

arrangements or payments that might be considered a conflict of

interests related to the present paper.

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