This study investigated attitudes toward people with intellectual disabilities among the general Hong Kong Chinese population and compared these to a White British sample, using the Community Living Attitudes Scale—Mental Retardation form (CLAS-MR; D. Henry, C. Keys, F. Balcazar, & D. Jopp, 1996). As predicted, attitudes among the Hong Kong Chinese public (n = 149) were less favorable than the British sample (n = 135). The former were less opposed to the exclusion of people with intellectual disabilities, less likely to view them as similar to themselves and more in favor of sheltering such individuals. Of all demographic variables examined, ethnicity was the strongest predictor of attitudes, although it only accounted for a small part of the variance in attitudes. The results are discussed in terms of policy implementation and additional research.
Current policies concerning people with intellectual disabilities in Western countries try to maximize social inclusion, independence, and empowerment. Although acceptance of people with intellectual disabilities by the general population is considered important for the success of these goals, to date, research into public attitudes to intellectual disability is very limited. Even less is known about attitudes among people from non-Western backgrounds. Culture has been shown to have a marked impact on attitudes to mental health, with East Asian cultures generally holding more stigmatizing attitudes and attributing greater shame to mental health problems (Furnham & Chan, 2004; Ng & Chan, 2000). However, we know little about the impact of culture on attitudes toward intellectual disability. Without such an understanding, it is difficult to assess the likely success of policies.
Intellectual disabilities affect 2% to 3% of the population worldwide and are defined as a significant impairment in intellectual functioning, with significant impairments in social (adaptive) functioning, which have an onset before adulthood (World Health Organization, 1992). In the United States and northern European countries, institutional care and segregation have been largely replaced with supported living in the community and policies that provide the legal right to full citizenship, social inclusion, and self-determination (e.g., U.S. Department of Health and Human Services, 2001, 2009).
In the past, distrust and hostility were the most commonly observed attitudes toward people with intellectual disabilities (Novak, 1993). In line with Allport's (1954) contact hypothesis, proponents of normalization argued that increased community inclusion was the best way to improve public attitudes toward people with intellectual disabilities (Wolfensberger, 1983). Regarding the link between community integration and attitudes, research has painted a somewhat mixed picture. Attitudes toward people with intellectual disabilities are thought to become significantly more positive with increased contact (Henry, Duvdevany, Keys, & Balcazar, 2004; Hudson-Allez & Barrett, 1996). However, some studies have failed to find a clear link between contact or, more generally, the progress of community integration and public attitudes toward intellectual disability and mental health problems (Hastings, Sjöström, & Stevenage, 1998; Schomerus, Matschinger, Kenzin, Breier, & Angermeyer, 2006; Yazbeck, McVilly, & Parmenter, 2004). This may be because the principles and values enshrined in policies and changes in service provision take time to permeate into public consciousness and are less positive in this state of transition. Overall, there is not much data on the relationship between efforts that promote more inclusion-friendly attitudes and changes in policies and public attitudes toward intellectual disability, and, so, this is an area for additional research.
A number of demographic factors may influence attitudes toward people with intellectual disabilities. Educational attainment has been found to be positively correlated with attitudes (Lau & Cheung, 1999; Yuker, 1994). Findings on the effects of age, gender and prior contact with someone with intellectual disabilities are less clear cut. While some studies found younger people, females and those with prior contact showed more positive attitudes (Gash & Coffey, 1995; Lau & Cheung, 1999; McConkey, McCormack & Naughton, 1983), others have failed to find such a relationship (Horner-Johnson et al., 2002; Hudson-Allez & Barrett, 1996).
Intellectual Disability Within a Hong Kong Chinese Context
Chinese society values conformity and the needs of the group take precedence over the needs of individuals (W. M. L. Lee, 1999). Academic achievement is greatly valued, as it may increase the status and wealth of the family (Uba, 1994). Failure to achieve academic or occupational success is seen as bringing shame on the whole family (E. Lee, 1997). It has been suggested that Confucian teachings regard deviations from the norm, such as intellectual disabilities or mental illness, as a punishment for the sins of ancestors, leading to a high level of stigma (Cheng & Tang, 1995). Therefore, such conditions in a family member are often hidden because they negatively affect the family's reputation. To avoid oversimplification, it should be stressed that Asian societies are changing rapidly due to the effects of modernization and industrialization. Recent widespread migration, particularly of younger people to urban areas, is likely to have marked effects on traditional values and traditional support networks that centered around the extended family. These changes are more pronounced in some highly industrialized Asian countries, including China and Hong Kong. It is possible in this context that attitudes toward disability may begin to deviate from traditional values. Furthermore, it should be noted that Hong Kong is a very unique environment due to its close ties to Britain for most of the 19th and 20th centuries; if anything, one might expect attitudes to be somewhat less in line with traditional values than in mainland China.
The development of mental health and intellectual disability services in Hong Kong has a very different history from Western countries. The first mental health ordinance was not passed until 1960, and the first long-stay hospital opened a year later (Hong Kong Government, 1972). Nongovernmental organizations (NGOs) began establishing community-based care in to follow the normalization initiatives sweeping the United States and northern Europe. It was not until 1976 that the government responded to demands for greater integration and issued the green paper, The Further Development of Rehabilitation Services in Hong Kong. Nevertheless, most services for people with intellectual disabilities were very limited and hidden from the public eye. After a violent crime committed by a former psychiatric inpatient in 1984, intense fear and stigmatization swept across all levels of society (Yip, 1991). In response, the construction of community-based homes within residential communities met strong opposition. Although hostilities and fear were initially directed at people with mental health problems, a lack of knowledge resulted in all forms of psychological problems, including intellectual disability, to be targeted (Tse, 1991). Numerous public education campaigns were launched to improve attitudes, but these have had minimal effect (Yip, 1998).
Inclusive education has been heralded as an important means to reducing barriers and achieving the greater social inclusion of children with disabilities. In contrast to many Western countries, inclusive education is minimal in Hong Kong; in 1998 only 0.1% of children with intellectual disabilities were in mainstream schools (Hong Kong Government, 1998). Wong, Pearson, Ip, and Lo (1999) noted that even this small number were only able to enter mainstream schools because of personal connections or by denying the child's disability. Although the Board of Education has made integration a key goal of educational reforms, lack of funding and of specialized teachers makes inclusive education an aspiration rather than a reality.
Although some studies have looked at attitudes toward mental health among Hong Kong Chinese people (Chou & Mak, 1998; Furnham & Chan, 2004; Ng & Chan, 2000), to our knowledge, public attitudes toward intellectual disability have not been formally examined. Understanding public attitudes toward the greater inclusion of people with intellectual disabilities in society has important implications for the likely success of efforts in this direction by the government and voluntary sector in Hong Kong. If negative attitudes prevail, attempts at greater community integration may be met with resistance and have limited success.
In the present study, we tried to assess beliefs about intellectual disability in the general Hong Kong Chinese adult population and to compare these attitudes with a White British sample. The specific purpose of this study was (a) to establish whether the attitudes of the Hong Kong Chinese public are in line with international efforts aimed at the greater integration and empowerment of people with intellectual disabilities, (b) to compare their attitudes with a White British sample, and (c) to examine the effect of demographics on attitudes, namely age, gender, educational attainments, and prior contact with someone with intellectual disabilities. We hypothesized that, in agreement with research in the area of mental health, Hong Kong Chinese adults would show less positive views toward people with intellectual disabilities than Westerners, in this case White British adults.
A total of 284 participants completed a short questionnaire packet; of these, 149 were Hong Kong Chinese and 135 were White British individuals. Hong Kong (HK) Chinese participants were recruited in public spaces, including shopping centers, main streets, and parks across Hong Kong and through opportunity sampling in mid- and late 2007. White British participants were recruited concurrently in London using a similar approach.
Apparatus and Materials
Participants completed a demographics questionnaire and the Community Living Attitudes Scale—Mental Retardation form (CLAS-MR; Henry, Keys, Balcazar, & Jopp, 1996). The CLAS-MR measures attitudes toward intellectual disability on four related but independent subscales: Empowerment, Exclusion, Sheltering, and Similarity. Empowerment reflects the view that people with intellectual disabilities should play an active role in making decisions affecting their lives, and essentially supports choice and self-advocacy. Exclusion taps the belief that people with intellectual disabilities should be excluded from society. Sheltering concerns the view that people with intellectual disabilities need help in their daily lives and protection from the risks of community life. It goes against the principle of independence but does not have the negative affective tone of Exclusion. Last, Similarity measures the extent to which a respondent views people with intellectual disabilities as similar to themselves, including assuming similar life goals and rights. While Empowerment and Similarity are mostly presented as positive and Exclusion and Sheltering as negative attitudes, Horner-Johnson et al. (2002) argued that Sheltering does not straightforwardly indicate negative attitudes. Given that people with intellectual disabilities may be vulnerable and in need of support, Horner-Johnson et al. suggested that endorsement of Sheltering at the very least showed that people with intellectual disabilities were valued enough to be worthy of care and concern. Responses in this study were scored on a 6-point Likert scale (1 = disagree strongly to 6 = agree strongly).
The CLAS-MR has distinct advantages over previous measures, namely it assesses attitudes closely in agreement with current policy values; it was developed with people with intellectual disabilities and, thus, reflects their concerns; and its reliability and validity has been confirmed in a number of studies across cultural contexts (Henry, Keys, Balcazar, & Jopp, 1996; Henry, Keys, Jopp, & Balcazar, 1996; Horner-Johnson et al., 2002; Schwartz & Armony-Sivan, 2001; Yazbeck et al., 2004). Results from previous studies with community samples are presented in Table 1.
For the present study, three alterations were made to the CLAS-MR: (a) The word mental retardation in the original version of the CLAS-MR was replaced with the terms learning disabilities for the British version and intellectual disabilities for the Hong Kong version; (b) in both versions a note was added at the beginning of the questionnaire—“People with learning disabilities/intellectual disabilities are sometimes known as ‘mentally handicapped’”—to increase the likelihood that participants in both nations would understand what they were being asked; (c) and six items were added to reflect specific cultural issues and beliefs that may be common among Asians (Items 41–46; see Table 7). It has been suggested that beliefs that intellectual disabilities can be overcome or “cured” through medical or religious interventions, or marriage, are more common in at least some Asian cultures (Items 41 to 43) (Channabasavanna, Bhatti, & Prablu, 1985). An emphasis in Eastern cultures on family and community cohesion rather than individual autonomy (E. Lee, 1997) may be reflected in a belief that parents, rather than services, should bear the main responsibility for the care of children with disabilities (Item 44). Last, Hughes (1983) suggested that within some Asian cultures the stigma associated with intellectual disability is so marked that families may fear that the marriage prospects of siblings will be damaged as a result of having a family member with intellectual disabilities or feel that the person should be hidden from society (Items 45 and 46).
For the HK Chinese sample, all measures were available in English and Chinese versions. The measures were translated by the second author (K. K.) and cross-examined by three additional bilingual English and Cantonese speakers. The final version was piloted and further amendments were made.
Participants were approached in person and asked to complete a 15-min questionnaire. HK Chinese participants were given a choice between the English and Chinese versions. Ethical approval for the study was granted by the University College London Research Ethics Committee.
The average ages of both samples were similar: 37.17 years (SD = 15.72 years) for the HK Chinese and 33.92 years (SD = 18.15 years) for the White British sample, t(282) = −1.608, p = .109. In both samples, women outnumbered men to a similar degree, χ2(1, N = 284) = 0.241, p = .623. Educational attainments showed a very different picture for the HK Chinese sample, who were more concentrated at both the bottom and top ends. HK Chinese people were far less likely to report prior contact with someone with an intellectual disability than their British counterparts, χ2(1, N = 279) = 82.70, p < .001. The demographic characteristics of the participants are shown in Table 2.
Attitudes Toward Community Living
For both samples, the four CLAS-MR subscales were correlated significantly and in the same directions as previous studies that have used the measure, namely both Empowerment and Similarity were negatively correlated with the other two subscales (Henry, Keys, Balcazar, & Jopp, 1996; Henry, Keys, Jopp, & Balcazar, 1996; Horner-Johnson et al., 2002; Henry et al., 2004). The reliability of the subscales was acceptable for both samples, indicating that HK Chinese attitudes toward people with intellectual disabilities follow the same factor structure as that found in other cultural groups (see Table 3).
Overall, the HK Chinese sample displayed attitudes that were broadly in line with current policies, if not altogether overly favorable of the full inclusion of people with intellectual disabilities. Subscale scores for Empowerment, Sheltering, and Similarity fell around the midway mark (3 = disagree somewhat, 4 = agree somewhat; see Table 4).
A multivariate analysis of covariance (MANCOVA) was conducted to determine the relationship of the CLAS-MR subscales to ethnicity, while controlling for prior contact, which differed significantly between the two groups. Ethnicity had a significant effect on the combined CLAS-MR subscales, F(4, 278) = 12.17 (Pillai's trace), p < .001, η2p = .15. There were significant differences on three subscales, with HK Chinese adults scoring higher on Exclusion and Sheltering and lower on Similarity (see Table 4). Although the multivariate effect suggests cultural differences across the range of attitudes, the effect sizes on individual subscales were small.
Effect of Demographics on Attitudes
As noted, gender, age, educational attainment, and prior contact have been shown, at least in some previous studies, to influence attitudes toward people with intellectual disabilities. The relationship between CLAS-MR subscale scores and these demographic variables was examined. Descriptive statistics for the CLAS-MR subscales by demographic variables are shown in Table 5.
Age was correlated with Sheltering (r = .19, p < .01) but no other subscale, when controlling for ethnicity. Older participants, regardless of ethnicity, were more likely to favor the protection and supervision of people with intellectual disabilities. Education was correlated with Empowerment (r = .13, p < .05) and Similarity (r = .23, p < .001), when controlling for ethnicity. Those with higher levels of education were more likely to advocate empowerment and view people with intellectual disabilities as similar to themselves. Multiple regressions were conducted to examine the ability of ethnicity, gender, and prior contact to predict the CLAS-MR subscale scores. None of these variables predicted Empowerment scores. For Exclusion, ethnicity predicted 8% of the variance and gender an additional 3%. For Sheltering and Similarity, ethnicity was the only predictor, yet it only predicted 4% and 7%, respectively, of the variance. Of note, prior contact with someone with intellectual disabilities did not predict any of the subscale scores (see Table 6).
Additional Items 41–46
These items were added to the CLAS-MR to tap into attitudes that may be more prevalent within Asian cultures. As they have not been validated they were analyzed separately (see Table 7). A MANCOVA was conducted to determine the relationship of ethnicity to the six additional items, while controlling for age, prior contact, gender, and education. Ethnicity, F(6, 260) = 33.58 (Pillai's trace), p < .001, η2p = .44, and gender, F(6, 260) = 3.56 (Pillai's trace), p < .01, η2p = .08, had a significant effect on the six combined items. HK Chinese participants were significantly more likely to agree, or less likely to disagree, with all six items. Differences by ethnicity were most pronounced regarding the beliefs that intellectual disabilities can be cured through medical interventions or overcome through religion and statements suggesting increased stigma and family shame associated with intellectual disability (Items 45 and 46). Women were more likely to agree with Items 41, 43, 45, and 46, although all effect sizes for gender were very small.
Because these items were designed to tap specifically into Asian attitudes that may be missed by the CLAS-MR, their relationship to the CLAS-MR subscales was examined for the HK Chinese sample (see Table 8). The results suggested that Item 41 in particular, which focuses on the belief that intellectual disabilities can be cured through medical interventions, tapped into a belief not covered by the CLAS-MR and far more prevalent among the HK Chinese sample than the White British one.
Last, we examined how the current results compared with previous studies that have used the CLAS-MR, either with community or student samples (Henry, Keys, Jopp, & Balcazar, 1996; Horner-Johnson et al., 2002; Schwarz & Armony-Sivan, 2001). Because we did not have access to these studies' original data, one-sample t tests were performed to compare sample means, given that the standard deviations for our sample and all previous samples all fell within a fairly narrow range (.47–.83). Both the White British and HK Chinese samples were more in favor of Empowerment than all these previous samples; compared with Henry, Keys, Jopp, and Balcazar (1996), who reported the most favorable views toward Empowerment: White British, t(134) = 3.35, p = .001; HK Chinese, t(148) = 3.17, p = .002. Both samples agreed in general with the previous studies cited on Sheltering and Similarity. However, the HK Chinese sample was more in favor of Exclusion than any previously studied samples (cf. Henry, Keys, Jopp, & Balcazar, 1996; Horner-Johnson et al., 2002): t(148) = 6.64, p < .001.
In this study, our goal was to examine attitudes toward intellectual disability among the general Hong Kong Chinese population and to compare these with a White British sample. As predicted, we found that the former group held less favorable attitudes on three of the CLAS-MR's four subscales. That they were less opposed to exclusion may reflect the two countries' very different histories in advancing the social inclusion of people with intellectual disabilities and the finding that they were far less likely to have had prior contact with anyone with intellectual disabilities. They were more likely to view them as in need of protection and supervision, which may be seen as in line with cultural values that privilege community and interdependence over individual needs and autonomy. This group was also less likely to view individuals with intellectual disabilities as similar to themselves. As noted in the introduction, research suggests that any form of mental disorder is highly stigmatised in Hong Kong society, which is likely to be at the root of the social distancing from people with intellectual disabilities found in this study. Of note though, ethnicity only accounted for a relatively small part of the variance in attitudes after other demographic factors were taken into account. This may have been due, at least in part, to the fact that education, in agreement with previous research, was found to influence attitudes (Lau & Cheung, 1999; Yuker, 1994) and that the HK Chinese sample was more educated than the White British sample. Of the former, 50% of the group had been educated to diploma or degree level, compared with only 20% of the latter group. However, in the current study, education only influenced attitudes in two areas after ethnicity was controlled for; those with additional education were much more likely to view people with intellectual disabilities as similar to themselves and somewhat more likely to support their empowerment. With regard to other demographic factors, age and gender had only small effects on attitudes after ethnicity was controlled for.
When comparing our findings with previous studies, in general, responses in the current study were encouraging. Attitudes displayed by both White British and HK Chinese participants toward the community inclusion of people with intellectual disabilities generally agreed with previous studies, most of which sampled students who were known to show more positive attitudes toward disability than members of the general population. This suggests that efforts of disability rights activists and the self-advocacy movement are leading to more positive attitudes, particularly in terms of a recognition of a right for choice and self-determination. However, the results suggest that, in a Hong Kong context, a belief in empowerment is not necessarily accompanied by attitudes favoring the social inclusion of individuals with intellectual disabilities. Whether the results imply increasingly positive attitudes among HK Chinese people is a question for additional research. Individuals with additional education were overrepresented in this sample, and, thus, caution should be exercised in generalizing the findings. As noted, educational attainment predicted Empowerment and Similarity scores but not Exclusion scores, suggesting that the apparent support for Empowerment may have been a direct result of the higher level of education among the Hong Kong sample and painted an overly positive picture. Although we controlled for educational attainment, it is possible that education has a larger effect on an Asian sample than it had on the current combined White British/HK Chinese sample. Furthermore, although all participants in the Hong Kong sample were of Chinese ethnicity, differences between Hong Kong and Chinese society and economic circumstances cannot be stressed enough.
Marked differences between the two samples in the likelihood of prior contact are worth noting. While 71 per cent of the British group said they knew someone with intellectual disabilities, only 17 per cent of the Hong Kong Chinese sample did. This finding indicates that community integration has a long way to go in Hong Kong.
The CLAS-MR's subscales were correlated in the same direction as in previous studies. In agreement with previous research, this suggests that the measure is a valid and reliable tool to examine attitudes toward intellectual disability in diverse cultural contexts. Six items were added to the CLAS-MR in the current study in an attempt to tap into specific Asian beliefs. These items identified beliefs in the curability of intellectual disabilities and associated greater stigma and family shame, which had some support among the HK Chinese sample. Despite attitudes on a standardized measure emerging on the positive side of neutral, as long as highly stigmatizing and exclusionist beliefs are present within a culture (see Item 45), there appears to be a large gap between the idea and reality of the full social acceptance of this group. Furthermore, an examination of the relationship between these items and the CLAS-MR suggests that at least some of these items should be considered for inclusion in future studies with non-Western populations because they appear to tap into attitudes that are distinct from those covered by the CLAS-MR.
Although contact with individuals with intellectual disabilities has consistently been regarded as a key route to improving attitudes, prior contact did not predict attitudes in the current study, in agreement with previous studies (Schwartz & Armony-Sivan, 2001; Yazbeck et al., 2004). This may be due to the somewhat crude measurement, which simply asked participants to specify whether they knew someone with intellectual disabilities and in what capacity. In agreement with research on the conditions in which contact has a positive effect on attitudes, future research should examine mediating mechanisms more carefully, including the quality of interactions and affective factors, that is whether the contact was approached with positive emotions or anxiety, which can prime negative outcomes (Dovidio, Gaertner, & Kawakami, 2003).
There were some limitations in this study. The relatively small sample sizes and the fact that the HK sample was highly educated raise questions as to how representative our findings are. That 83% of the Hong Kong sample had never encountered someone with intellectual disabilities raises the issue of accuracy in understanding the concept of intellectual disability, on which participants' responses were based. British participants may also have experienced misconceptions about the meaning of the term learning disability, as suggested by a recent large population survey (Mencap, 2008). Thus, the current results may give an overly positive picture of attitudes toward this group, and future research should include a more detailed definition of the concept. Another limitation is that we are unsure how attitudes might translate into behavior in real life, as we only examined respondents' attitudes on the questionnaire measure, that is, on paper. Based on a meta-analysis, Kraus (1995) concluded that there is a substantial association between attitudes and behavior. Last, only attitudes were examined in the current study. Future research should investigate knowledge about intellectual disability and include a measure of social distance (see, e.g., Jorm & Oh, 2009).
In conclusion, our results suggest a positive shift toward more inclusion-friendly attitudes compared with earlier studies. For a Hong Kong context though, the low rates of prior contact and proexclusion views encountered indicate that a much stronger push toward social inclusion of people with intellectual disabilities is called for. There were also indications that highly stigmatizing views of intellectual disability persist among some parts of the population. Future efforts aimed at the increased acceptance and social inclusion of individuals with intellectual disabilities may have a better chance of success if they emphasize empowerment and a common humanity, as these attitudes were generally favored. Overall, these findings suggest that such efforts in any cultural context should be informed by a careful analysis of local attitudes, rather than a “one size fits all” approach.
Katrina Scior, BSc DClinPsy (E-mail: firstname.lastname@example.org), Senior Lecturer, University College London, Clinical, Educational & Health Psychology, London, United Kingdom. Ka-ying Kan, BSc, University College London. Anna McLoughlin, BSc, University College London. Joel Sheridan, BSc DClinPsy, Camden & Islington Foundation Trust.
Editor-in-Charge: Marji Erickson Warfield