Generally, rural/urban classification was not the sole and decisive predictor of level of stigma around mental illness.

Please read the Results and Discussion sections of the article below.
In a short essay format, please describe the participants and procedure. Please be sure to include enough detail to satisfy the following questions:
In general, what are the results of the study? For example, is there a relationship between the variables? Is that relationship stronger or weaker for some of the participants? Are the results statistically significant? Do NOT try to describe statistical procedures or calculations.

Do the results support the hypotheses? Was this—or any other aspect of the findings—unexpected?
What is/are the authors’ major conclusions(s) based on the results? Why do they believe they received those results?
DO NOT PLAGIARIZE OR USE CHAT GPT ALL WRITING MUST BE IN YOUR OWN WORDS.

Results
Prior to weighting the data, 81% of respondents were female (18% male), 35% had no 4-year degree, 40% had a bachelor’s degree, and 25% had a master’s degree, professional or doctoral degree, 63% lived in a rural area, and 52% were between the ages of 18 and 41 years. Tables 2, 3, 4, and 5 present our findings for the regression exercises described above for each of the seven stigma measures. Significantly positive (negative) coefficients imply greater (lower) stigma perception, all else equal, relative to our comparison group. We also ran retrospective power analyses for our benchmark multiple linear regression models where the alternative hypothesis was that the slope coefficients were nonzero. The estimated power ranged from 0.751 to 1.000 with the overwhelming majority with power above 0.95. However, we stress that such power estimates should be viewed with caution as they suffer from the demonstrated conclusion that higher observed power does not necessarily imply stronger evidence for a null hypothesis that is not rejected (Hoenig and Heisey, 2001).
A key and robust finding from our analysis was that females exhibited lower stigma perceptions than males. For example, in our benchmark regressions (Table 1), the coefficient to gender was negative and significant for all stigma measures except visibility, recovery, and treatability. In those latter three cases, the coefficient was insignificant but the point estimate was still negative.2
In subsequent exercises, we explored if other factors explained these differences between females and males in stigma perceptions. The results from Table 3, where rural interaction terms were included into the benchmark specification, suggest that, generally, rural females hold higher degrees of stigma perceptions compared to urban females. For most of the stigma measures, we found the coefficient to the rural-gender interaction term was positive and significant. The exceptions were for anxiety, visibility, and professional efficacy. In these cases, the point estimate was positive for all except visibility; the point estimates were not significantly different from zero in all cases.
Older females (ages 36 –50 years and 51 years and older) generally exhibited lower degrees of stigma perceptions compared to females in the 35 years and younger age-group (Table 4). The sole exception was visibility where the point estimates to the gender and age-groups interaction terms were positive. In all other cases, the point estimates were negative and, in most cases, highly significant.
We explored further by putting all the interaction terms—both rural and gender interaction terms—into the benchmark model, and, important, including a set of three-way interaction terms between rural–gender–age groups (Table 5). The results generally confirmed the robustness of the above findings but shed new light on the complex heterogeneity in stigma perceptions within the female population. In almost all cases (with the exception of anxiety and professional efficacy), we found that urban females who are aged 35 years and younger actually held views that were not significantly different from their male counterparts in the comparison group, all else equal. In the case of anxiety and professional efficacy, they actually held stronger (higher level) views regarding stigma than corresponding males. Except in two cases (anxiety and visibility), rural females aged 35 years and younger held views that were not significantly different from their urban female counterparts, and in those two cases, their views were actually more moderate.
Although older urban males tended to exhibit higher levels of stigma perception relative to the comparison group, rural males actually had significantly more moderate views. Higher levels of education did not generally appear to moderate the views of males either (although they tend to do so for females) regardless of whether they lived in urban or rural areas. For example, we found that more highly educated males actually exhibited higher degrees of stigma perception for anxiety, while, for the other stigma measures, the effect of higher education appeared to be largely insignificant.
The effect of having a family member or partner who had experienced mental health issues on a person’s stigma perceptions was mixed. For example, such direct experience with mental illness appeared to have a moderating (negative) effect for anxiety, professional efficacy, hygiene, and recovery depending on the specification. However, for visibility (see

Table 3), respondents in urban areas with such direct experiences were more likely to say that they could visibly identify someone with mental health issues while similar respondents in rural areas reported the opposite. The results were, for example, reversed for recovery with urban residents with such direct experiences being generally more optimistic about the prospects for recovery compared to rural residents.
In sum, our findings suggest that different social groups characterized by gender, rural-urban classification, and direct experiences with mental illness hold complex and, in some cases, drastically different views in terms of stigma.

Discussion
We sought to determine the level of public stigma around behavioral health disorders between rural and urban residents within the state, subsequently adding to the literature a discussion around rural and urban mental health stigma. Generally, rural/urban classification was not the sole and decisive predictor of level of stigma around mental illness. Instead, there was variability between gender and age. More complicated is that when one group of individuals presented with stronger feelings of stigma, they did not necessarily do so across all seven measures of stigma. The complexity of these findings indicate that mental health literacy should target messaging and focus based on population demographics.
This finding is substantiated by a 2016 study that explored antistigma programming from different countries in an attempt to develop evidenced-based best practices (Stuart, 2016). The 2016 analysis stated that it is imperative that dollars are allocated toward targeted, contact-based stigma interventions and not large public educational approaches. Large educational campaigns developed to address stigma assume all communities and demographic groups approach mental illness in the same way and hold similar levels of stigma that we found not to be the case, and which this study found largely ineffective (Stuart, 2016). A 2015 study focused specifically on interventions on self-stigma indicated the same by highlighting common elements and important distinctions between interventions and which of those work best for particular populations (Yanos et al., 2015).
ROLE OF GENDER AND RURAL/URBAN CLASSIFICATION
Females exhibited lower stigma perceptions than males. However, rural females held higher degrees of stigma perceptions compared to urban females. This is consistent with a 2015 study in Western Kentucky that concluded that psychiatric nurses needed to develop community-based interventions to reduce both personal and public stigma among rural females specifically (Simmons et al., 2015).
We also found that older females (those aged 36–50 years or 51 years and older) generally exhibited lower degrees of stigma perceptions compared

with females aged 35 years and younger. Driving the differences in female views on stigma relative to our comparison group were the views of older urban females (those aged 36–50 years and also those 51 years and older). Given that females, especially those who were older and living in urban communities held less stigma than their counterparts, this subgroup can be utilized as champions of care. Education campaigns can utilize these champions within the community and beyond to create a safe environment for accessing mental health services and treatment.
Similarly, these findings indicate a need to address mental health literacy among males in rural and urban communities alike. However, campaigns and mental health promotion must recognize that rural males and urban males will likely have various perceptions of mental illness and variable stigma. These findings not only call for a need to address stigma and misperceptions around mental illness but also illustrate the need to conduct similar research in each state/community prior to implementing educational programing or health campaigns. This will allow dollars to be appropriately allocated and will encourage more effective education.
RELATIONSHIP TO SOMEONE WITH MENTAL ILLNESS
Direct experience with mental illness had a moderating (negative) effect for anxiety and hygiene. Having a close familial relation to someone with a mental illness mitigated the level of stigma around mental illness, more generally. These findings indicate that those who have a close relationship with someone who has a mental illness can serve as community champions. Mental health literacy and stigma mitigation must focus on those who have less experience interacting with someone with mental illness. Urban residents with such direct experiences were more optimistic about recovery compared to rural residents with direct

experience which would indicate that there is still a need to address recovery in rural communities.
CONCLUSION
Stigma about mental illness can prevent treatment and recovery among those with mental illness, poses a barrier for public health prevention efforts, and can lead to poorer quality of care delivered for those with mental illness (CDC et al., 2012). This study identified subpopulations who hold greater stigma, subpopulations who can serve as community champions in rural areas, identified groups in need of mental health education, and also identified specific measures of stigma requiring focused educational campaigns.
LIMITATIONS AND FUTURE RESEARCH
Limitations included the snowball sampling frame, which resulted in a sample that was largely influenced by female respondents and those with a college degree. However, the results were weighted to overcome this limitation. It is important to note that the large degree of bias in the sample likely could not be entirely controlled for through weighting. Even recognizing that there is a potential bias and an inability to generalize the results of this survey to all adults in North Dakota, the data do establish a strong baseline and support for addressing stigma among males in rural and urban communities throughout the state. Results also highlight, regardless of generalizability of these specific data, the need to survey and assess stigma around mental health prior to implementing educational campaigns developed to address/decrease public stigma.

Another limitation of this study is that it did not explore perceived self-stigma by individuals with mental illness, which can have a greater influence on care utilization than public stigma. The study also explored stigma in only one state and did not explore potentially exacerbating variables because of small sample sizes. However, this study is one of the first to explore variable public stigma between rural and urban areas.
The original survey assessed stigma around several mental health diagnoses. A limitation of that study was its length and noncompletion rate. To accommodate that limitation, this study measured stigma related to mental illness more broadly. This is also a limitation because there was no distinction between AMI and serious mental illness. It is recommended that future research assess stigma around AMI (not including serious mental illness but including diagnoses like depression and anxiety) and then assess stigma related more specifically to serious mental illness. Serious mental illness would include diagnoses such as bipolar disorder and schizophrenia.
The results draw attention to the need for future research to break perceived stigma (self or public) into categories like those studied (professional efficacy, anxiety, hygiene, etc.) and the need to identify both

community champions (subgroups with low stigma) and priority health education topics (for example, the topic of recovery among rural males). Future research may also explore additional demographic variables that could influence community stigma (e.g., income). Within the state of study, there is an opportunity to now develop focused educational and mental health promotion campaigns and to subsequently study their impact on public stigma.

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