Factors underlying differences in knowledge, explicit stigma and implicit bias towards autism

Autism stigma involves negative attitudes, stereotypes, and discrimination towards autistic individuals.

This stigma can lead to social exclusion, reduced opportunities, and poorer mental health outcomes for autistic people.

It may also contribute to both explicit and implicit biases in society. Studying autism stigma is crucial to understand its root causes, develop effective interventions to reduce prejudice, and promote more inclusive attitudes.

This research can inform policies and practices that improve the quality of life for autistic individuals and foster a more accepting society.

Cheng, Y., Dwyer, P., & Keating, C. T. (2025). Factors underlying differences in knowledge, explicit stigma and implicit biases towards autism across Hong Kong, the United Kingdom and the United States. Autism, 29(4), 868-883. https://doi.org/10.1177/13623613241290565

Key Points

• The study explored cross-cultural differences in knowledge, explicit stigma, and implicit biases towards autism across Hong Kong, the United Kingdom, and the United States.
• Research aim: Assess the contribution of knowledge and cultural orientation to explicit stigma and implicit biases towards autism.
• Research aim: Compare levels of knowledge, explicit stigma, and implicit biases across the three countries after controlling for relevant covariates.
• Key findings: Explicit stigma was predicted by less accurate knowledge, lower horizontal collectivism, greater vertical individualism, and higher implicit biases. Students in Hong Kong displayed less accurate knowledge and higher explicit stigma towards autism compared to those in the UK and US, but implicit biases did not differ between countries.
• Implications: The findings highlight the need to combat misconceptions about autism to improve attitudes, especially in Hong Kong. However, acquiring more accurate knowledge may not be sufficient to alter unconscious biases.

Rationale

The study addresses the growing concern of stigma faced by autistic individuals in their daily lives, which can lead to exclusion, bullying, and poorer mental and physical health outcomes (Botha & Frost, 2020; Cage et al., 2018).

Previous research has identified cross-cultural variations in autism-related stigma, with higher levels observed in countries like South Korea, Japan, Lebanon, and Malaysia compared to the United States or United Kingdom (Gillespie-Lynch et al., 2019; Kim et al., 2022; Obeid et al., 2015; Someki et al., 2018).

These differences may be explained by varying levels of autism knowledge or cultural value orientations. However, most prior studies have relied on self-report measures of explicit attitudes, neglecting the examination of implicit biases.

This study aims to fill this gap by investigating both explicit and implicit attitudes towards autism across three culturally diverse countries, providing a more comprehensive understanding of the factors underlying autism-related stigma and knowledge.

Method

Procedure

Cross-sectional survey design

Steps:

1. Participants provided informed consent
2. Completed demographic questions
3. Completed Social Distance Scale (SDS)
4. Completed Participatory Autism Knowledge Measure (PAK-M)
5. Completed Culture Orientation Scale
6. Completed autism-related Implicit Association Test (IAT)

Sample

• Total participants: 361 university students
• Hong Kong: 119
• United Kingdom: 120
• United States: 122
• Age (mean): Hong Kong (22.26), UK (28.74), US (26.02)
• Gender: Predominantly cisgender female (63.0% HK, 65.8% UK, 54.9% US)
• Ethnicity: Primarily Chinese in Hong Kong (81.5%), White in UK (70.0%) and US (64.8%)

Measures

1. Social Distance Scale (SDS): 11-item questionnaire measuring willingness to engage with autistic individuals
2. Participatory Autism Knowledge Measure (PAK-M): 29-item true/false questionnaire assessing autism knowledge
3. Culture Orientation Scale: 16-item questionnaire measuring four components of cultural orientation
4. Implicit Association Test (IAT): Measures automatic associations between autism diagnostic labels and personal attributes

Statistical measures

• Multiple regression and non-parametric multiple regression
• Analyses of covariance (ANCOVAs)
• Wilcoxon signed-rank tests
• Post-hoc Bonferroni-corrected tests
• Exploratory mediation analyses using structural equation modeling (SEM)

Results

Hypothesis 1: Those with greater knowledge about autism, higher horizontal collectivism (seeing oneself as part of a collective whose members are considered equal), and lower vertical individualism (seeing oneself as autonomous within a justly hierarchical system) would exhibit lower levels of explicit autism-related stigma.

Results: Supported. Explicit stigma was negatively predicted by autism knowledge (t(345) = -10.46, p < 0.0001) and horizontal collectivism (t(345) = -2.03, p = 0.0428), and positively predicted by vertical individualism (t(345) = 6.35, p < 0.0001) and implicit biases (t(345) = 2.17, p = 0.0306).

Hypothesis 2: Levels of explicit stigma and implicit biases would be higher in Hong Kong than in the United Kingdom and United States.

Results: Partially supported. Explicit stigma was significantly higher in Hong Kong compared to the UK (W = 11,656, pbonf < 0.0001) and US (W = 11,519, pbonf < 0.0001). However, there were no significant differences in implicit biases between countries (F(2, 354) = 0.86, p = 0.422).

Additional findings:

• Implicit biases were positively predicted by age (t(345) = 2.27, p = 0.0237) and explicit stigma (t(345) = 2.17, p = 0.0306).
• Autism knowledge was negatively predicted by vertical individualism (t(347) = -3.05, p = 0.0025) and vertical collectivism (t(347) = -2.39, p = 0.0175), and positively predicted by horizontal individualism (t(347) = 3.45, p = 0.0006) and horizontal collectivism (t(347) = 4.38, p < 0.0001).
• University students in Hong Kong displayed significantly lower levels of autism knowledge compared to those in the UK (t(237) = -7.16, pbonf < 0.0001) and US (t(239) = -6.09, pbonf < 0.0001).

Insight

This study provides valuable insights into the complex interplay between cultural factors, knowledge, and attitudes towards autism across different countries.

The finding that explicit stigma was higher in Hong Kong, while implicit biases did not differ between countries, suggests that cultural norms and social desirability may play a significant role in shaping explicit attitudes.

This highlights the importance of considering both explicit and implicit measures when studying cross-cultural differences in autism stigma.

The study extends previous research by demonstrating that vertical individualism and horizontal collectivism indirectly affect implicit biases through explicit stigma.

This suggests that cultural orientation may influence explicit attitudes, which in turn shape implicit biases over time.

These findings provide a more nuanced understanding of how cultural factors contribute to autism stigma and knowledge.

Future research could explore the effectiveness of culturally tailored interventions to reduce autism stigma, particularly in Hong Kong.

Additionally, longitudinal studies examining how cultural orientation, explicit attitudes, and implicit biases change over time or when individuals move between cultures could provide further insights into the causal relationships between these factors.

Implications

For practitioners:

1. Develop targeted educational programs to improve autism knowledge, especially in Hong Kong.
2. Incorporate cultural sensitivity training in autism awareness initiatives to address the influence of cultural orientation on attitudes.
3. Design interventions that address both explicit and implicit biases, as reducing explicit stigma alone may not be sufficient to change underlying implicit attitudes.

For policymakers:

1. Allocate resources for cross-cultural research on autism stigma to inform evidence-based policies.
2. Implement policies that promote inclusive education and workplace practices to reduce stigma towards autistic individuals.
3. Support initiatives that challenge vertical individualism and promote horizontal collectivism to foster more inclusive attitudes towards autism.

Potential benefits:

• Improved social inclusion and quality of life for autistic individuals
• Reduced discrimination in educational and employment settings
• Enhanced cross-cultural understanding and cooperation in autism research and support

Challenges:

• Resistance to changing deeply ingrained cultural values and beliefs
• Limited resources for implementing large-scale educational programs
• Difficulty in addressing implicit biases that may be less responsive to traditional interventions

Strengths

This study had several methodological strengths, including:

• Cross-cultural comparison of three diverse countries
• Examination of both explicit and implicit measures of autism stigma
• Use of validated measures for assessing knowledge, cultural orientation, and attitudes
• Controlling for relevant covariates in cross-country comparisons
• Inclusion of exploratory mediation analyses to examine indirect effects

Limitations

This study also had several methodological limitations, including:

• Reliance on university student samples, limiting generalizability to the broader population
• Potential self-selection bias in participant recruitment
• Use of English-language measures across all countries, potentially excluding non-English speakers
• Cross-sectional design limiting causal inferences
• Possible influence of social desirability bias on self-reported measures

References

Primary reference

Cheng, Y., Dwyer, P., & Keating, C. T. (2025). Factors underlying differences in knowledge, explicit stigma and implicit biases towards autism across Hong Kong, the United Kingdom and the United States. Autism, 29(4), 868-883. https://doi.org/10.1177/13623613241290565

Other references

Botha, M., & Frost, D. M. (2018). Extending the Minority Stress Model to Understand Mental Health Problems Experienced by the Autistic Population. Society and Mental Health. https://doi.org/10.1177/2156869318804297

Cage, E., Di Monaco, J., & Newell, V. (2018). Experiences of autism acceptance and mental health in autistic adults. Journal of autism and developmental disorders, 48, 473-484. https://doi.org/10.1007/s10803-017-3342-7

Gillespie-Lynch, K., Daou, N., Sanchez-Ruiz, J., Kapp, S. K., Obeid, R., Brooks, P. J., Someki, F., Silton, N., & Abi-Habib, R. (2019). Factors underlying cross-cultural differences in stigma toward autism among college students in Lebanon and the United States. Autism. https://doi.org/10.1177/1362361318823550

Kim, S. Y., Cheon, J. E., Gillespie-Lynch, K., & Kim, Y. H. (2022). Is autism stigma higher in South Korea than the United States? Examining cultural tightness, intergroup bias, and concerns about heredity as contributors to heightened autism stigma. Autism, 26(2), 460-472. https://doi.org/10.1177/13623613211029520

Obeid, R., Daou, N., DeNigris, D., Shane-Simpson, C., Brooks, P. J., & Gillespie-Lynch, K. (2015). A cross-cultural comparison of knowledge and stigma associated with autism spectrum disorder among college students in Lebanon and the United States. Journal of autism and developmental disorders, 45, 3520-3536. https://doi.org/10.1007/s10803-015-2499-1

Someki, F., Torii, M., Brooks, P. J., Koeda, T., & Gillespie-Lynch, K. (2018). Stigma associated with autism among college students in Japan and the United States: An online training study. Research in Developmental Disabilities, 76, 88-98. https://doi.org/10.1016/j.ridd.2018.02.016

Socratic Questions

1. How might the use of university student samples impact the generalizability of the findings? What alternative sampling methods could be used to address this limitation?
2. The study found no differences in implicit biases across countries, despite differences in explicit stigma. What factors might contribute to this discrepancy, and how could future research investigate this further?
3. How might the cultural and historical context of each country (Hong Kong, UK, and US) influence attitudes towards autism beyond the measured cultural orientation factors?
4. Given the finding that knowledge about autism was negatively associated with vertical individualism and collectivism, how might educational interventions need to be tailored to address cultural values?
5. The study used English-language measures across all countries. How might this choice affect the results, particularly in Hong Kong? What alternative approaches could be used to ensure linguistic and cultural equivalence in cross-cultural research?
6. How might the relationship between explicit stigma and implicit biases change over time as societal attitudes towards autism evolve? How could longitudinal research designs contribute to our understanding of this relationship?
7. The study found that age was positively associated with implicit biases in the UK and US, but not in Hong Kong. What factors might explain this difference, and how could future research explore this finding further?
8. Considering the study’s findings, how might interventions to reduce autism stigma need to differ between countries with predominantly individualistic versus collectivistic cultures?
9. How might the experiences and perspectives of autistic individuals themselves contribute to our understanding of cross-cultural differences in autism stigma? How could future research incorporate these perspectives?
10. Given the challenges in addressing implicit biases, what innovative approaches or interventions could be developed to target both explicit and implicit attitudes towards autism across different cultural contexts?