STIGMATISING ATTITUDES TOWARDS MENTAL HEALTH CONDITIONS AMONG 
MEDICAL STUDENTS IN FIVE SOUTH-EASTERN EUROPEAN COUNTRIES
STIGMATIZIRAJOČI ODNOS DO DUŠEVNEGA ZDRAVJA MED ŠTUDENTI 
MEDICINE V PETIH DRŽAVAH JUGOVZHODNE EVROPE
Sanja HARHAJI1    , Sonila TOMORI2    , Vladimir NAKOV3    , Jana CHIHAI4    , Ivana RADIĆ1,5   , 
 Tedi MANA2    , Kaloyan STOYCHEV6    , Andrei ESANU4    , Mihail Cristian PIRLOG7* 
1Institute of Public Health of Vojvodina, Futoška 121, 21000, Novi Sad, Serbia
2Tirana Medical University, Rruga e Dibrës 371, AL1005, Tirana, Albania
3National Centre of Public Health and Analyses, Akad. Iv. E. Geshov Blvd 15, Sofia, Bulgaria
4Nicolae Testemitanu State University of Medicine and Pharmacy, Ştefan cel Mare şi Sfant Blvd 165 Chisinau, Moldova
5Faculty of Medicine, University of Novi Sad, Hajduk Veljkova 3, 21000, Novi Sad, Serbia
6Faculty of Medicine, Medical University Pleven, Sv. Kliment Ohridski 1, 5800, Pleven, Bulgaria
7Medical Sociology Department, University of Medicine and Pharmacy of Craiova, Petru Rares 2, 200349, Craiova, Romania
Received: Apr 10, 2024
Accepted: Aug 02, 2024
Original scientific article
*Correspondence: mihai.pirlog@gmail.com
10.2478/sjph-2024-0025 Zdr Varst. 2024;63(4):188-197
188© National Institute of Public Health, Slovenia. 
Harhaji S, Tomori S, Nakov V, Chihai J, Radic I, Mana T, Stoychev K, Esanu A, Pirlog MC. Stigmatising attitudes towards mental health conditions among medical students  
in five South-Eastern European countries. Zdr Varst. 2024;63(4):188-197. doi: 10.2478/sjph-2024-0025.
ABSTRACT
Keywords: 
Stigmatisation
Medical students
Mental disorders
Psychiatry
Mental health
IZVLEČEK
Ključne besede: 
stigmatizacija
študenti medicine
duševne motnje
psihiatrija
duševno zdravje
Introduction: Stigmatising attitudes towards mentally ill people are present among healthcare professionals. 
The aim of the study was to evaluate medical students’ attitudes in five medical schools from Albania, Bulgaria, 
Moldova, Romania and Serbia and to determine if psychiatry clerkship improves these attitudes.
Methods: In the first stage, the study included students from the first and final years of medical school; in the 
second stage, only final-year students were included; The Mental Illness Clinicians’ Attitude Scale (MICA-2) and 
the Attribution Questionnaire (AQ-9) were used in this study. The total sample comprised 1,526 medical students 
in the first stage and 614 in the second stage.
Results: The analysis of the average AQ-9 and MICA-2 scores between countries revealed significant differences 
(p<0.05). Multivariable analysis showed that female students were 30% more likely to have elevated AQ-9 scores 
than male students (p=0.029). Final-year students had a significantly lower chance of having a higher MICA-2 
score compared to first-year students (OR=0.7; p<0.05).
Conclusions: Psychiatry clerkship contributes to a decrease in the level of stigmatising attitudes among medical 
students. Further research is required to assess the curricula to achieve better results in reducing stigma among 
future doctors.
Uvod: Stigmatizirajoči odnos do duševno bolnih ljudi je prisoten tudi med zdravstvenimi delavci. Namen 
študije je bil oceniti stališča študentov medicine na petih medicinskih fakultetah v Albaniji, Bolgariji, Moldaviji, 
Romuniji in Srbiji ter ugotoviti, ali praksa na psihiatriji ta stališča izboljša.
Metode: V prvi fazi je študija vključevala študente prvega in zadnjega letnika medicinske fakultete, v drugi 
fazi pa samo študente zadnjega letnika; v tej študiji sta bila uporabljena lestvica stališč zdravnikov do duševnih 
bolezni (MICA-2) in vprašalnik o atribuciji (AQ-9). Skupni vzorec je obsegal 1526 študentov medicine v prvi fazi 
študije in 614 v drugi fazi.
Rezultati: Analiza povprečnih rezultatov AQ-9 in MICA-2 med državami je pokazala pomembne razlike (p < 0,05). 
Multivariatna analiza je pokazala, da je bila verjetnost, da bodo imele študentke za 30 % višji rezultat AQ-9 
kot študenti (p = 0,029). Študenti zadnjega letnika so imeli v primerjavi s študenti prvega letnika bistveno manj 
možnosti za višji rezultat MICA-2 (OR = 0,7; p < 0,05).
Zaključki: Psihiatrična praksa prispeva k zmanjšanju stopnje stigmatizirajočega odnosa med študenti medicine. 
Potrebne so nadaljnje raziskave za oceno učnih načrtov za doseganje boljših rezultatov pri zmanjševanju 
stigmatizacije med bodočimi zdravniki.
1 INTRODUCTION
According to WHO data, in 2019 over 12% of the world’s 
population suffered from a mental health condition (1), 
a rate which increased during the COVID-19 pandemic, 
especially regarding depressive and anxiety disorders 
(2). In this context, the effects of stigma associated with 
mental illnesses became more significant, necessitating 
new and more effective strategies to address it.
Defined by Erving Goffman, stigma comprises socially 
discrediting attributes, behaviours, or reputations leading 
individuals to be perceived as undesirable or abnormal (3). 
Stigma towards mentally ill people has two main forms: 
public stigma, often described as the general population’s 
reaction to mental health conditions, and self-stigma 
where individuals internalise societal prejudices (4, 5).
Public stigma is also prevalent among healthcare 
professionals (6, 7), with a special note on psychiatrists 
(8, 9) and medical students (10, 11). Medical students are 
an important target of anti-stigma campaigns, although 
the effectiveness of interventions varies (12-15). There are 
studies that have shown that medical students’ attitudes 
towards mental illnesses prior to psychiatric clerkship 
are similar to the general population in terms of negative 
beliefs and attitudes (16-19). There is data regarding the 
positive outcome of psychiatry clerkship (20-25). Other 
studies have shown that post-clerkship attitudes of 
students worsened based on newly gained beliefs about 
patients’ aggression and their unpredictable and dangerous 
behaviour, considering them as having poor prognosis or 
even being incurable, while working as a psychiatrist is too 
stressful and emotionally overwhelming (25-28).
Albania, Bulgaria, Moldova, Romania and Serbia share 
similar characteristics, not just their geographical 
location. Over the past three decades, both the healthcare 
and education systems in these countries have undergone 
continuous and slow reform (29). In the realm of mental 
health research, there is a scarcity of comparative studies 
focusing on the stigmatising attitudes of medical students 
towards individuals with mental illnesses in the contexts 
of these five countries. The length and content of 
psychiatry clerkship were quite similar across all countries 
involved in the research, consisting on average of 90 
academic hours per semester of lectures and practice in 
clinical psychiatry settings, without differences in content 
between the two stages of the study.
The aim of the study was to measure and compare medical 
students’ attitudes towards people with mental health 
conditions in the aforementioned countries, and to assess 
changes in these attitudes following psychiatric clerkships. 
We initially hypothesized that there would be no difference 
in stigmatising attitudes among medical students from 
these countries and that improved knowledge about 
mental health conditions would reduce negative attitudes.
10.2478/sjph-2024-0025 Zdr Varst. 2024;63(4):188-197
189
2 METHODS
2.1 Study settings
The study was conducted at faculties of medicine in 
five South-Eastern European countries as follows: Tirana 
Medical University, Albania; Pleven Medical University, 
Bulgaria; State Medical and Pharmaceutical University 
Nicolae Testemitanu, Chisinau, Moldova; University of 
Medicine and Pharmacy of Craiova, Romania; University 
of Novi Sad, Serbia.
2.2 Study stages
The study consisted of two stages: (I) the first, during 
academic year 2015/2016, included medical students 
from the first year of medical faculties and students in 
their final year; (II) the second, during academic year 
2020/2021, included only final-year medical students. 
Students surveyed in the second stage were mostly the 
same students included in the first stage when they were 
in the first year of their studies.
2.3 Study sample
In the initial stage of the research, we collected two 
convenience samples from each medical faculty: 
one comprising 860 first-year students and the other 
consisting of 666 final-year students. During the second 
stage, the study included only final-year students, with 
614 participants, after they had completed the psychiatry 
clerkship.
The inclusion criteria for first-year students were being 
registered and attending the medical faculty, while 
the additional criterion for final-year students was the 
completion of the psychiatry clerkship. There were no 
exclusion criteria at any stage of the study.
In the initial stage, printed questionnaires were distributed 
to students by their teachers during lectures or practical 
lessons on a voluntary basis. Response rates ranged from 
81.1% in Serbia to 44.8% in Albania. The second stage was 
conducted online due to the constraints imposed by the 
COVID-19 pandemic. Students received links to the web-
based questionnaire through their associations. Response 
rates decreased in all countries except Bulgaria, where 
the rate was 97.1%. The lowest response rate in the second 
stage was 16.2% in Moldova.
Participation in the study was voluntary, with students 
being informed of their right to decline involvement, as well 
ensuring the confidentiality and anonymity of both students 
and their responses. The study received approval from the 
ethics committees of the participating universities.
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190
2.4 Study measures
The questionnaire collected basic sociodemographic 
data, including age, gender and year of study. To assess 
stigmatising attitudes, two instruments were used: the 
Attribution Questionnaire (AQ-9) and The Mental Illness 
Clinicians’ Attitudes (MICA-2).
The AQ-9 measures medical students’ stigma by addressing 
nine stereotypes about individuals with mental illness, 
using a Likert scale ranging from 1 to 9. Higher scores 
indicate more stigmatising attitudes (30, 31).
The MICA-2 is a 16-item scale that measures attitudes 
towards psychiatry and mental health, perceptions of 
recovery and the dangerousness of individuals with 
mental illness, comfort levels around these individuals 
and discriminatory behaviour. Scores range from 1 to 
6, with higher total scores indicating more stigmatising 
attitudes (32).
Both questionnaires underwent back-translation into the 
national languages of the countries involved (Albanian, 
Bulgarian, Romanian and Serbian), ensuring linguistic 
and cultural relevance. Cronbach’s alpha values were 
satisfactory across three measurements, indicating 
acceptable internal consistency.
2.5 Statistical analysis
Standard methods of descriptive and inferential statistics 
were used. Numerical data were presented as mean (M) and 
standard deviation (SD), while categorical characteristics 
were depicted through frequency distributions. Univariate 
analyses were performed using Pearson’s χ2 test, Student’s 
t-test, and χ2 (ANOVA).
Binary logistic regression (Enter method) was used to 
assess the relationship between stigma and independent 
variables (gender, year of study and country). Crude and 
adjusted Odds Ratios (OR and AOR) were calculated. 
The independent variables, such as gender and year of 
study, were selected for the multivariable analysis model 
based on empirical variable selection, while the country 
variable was included based on the study’s objectives. 
The AQ-9 score and MICA-2 scores as dependent variables 
were dichotomized around the median of the total sample 
into two categorical variables: AQ-9 scores were classified 
as low (9-35) or high (36 and above), and MICA-2 scores 
were classified as low (16-51) or high (52 and above). 
This analysis focused on the initial stage of the research 
(academic year 2015/2016) and Serbia was selected as 
the reference country due to its lowest average AQ-9 and 
MICA-2 scores. 
Significance level was set at p<0.05. Statistical analyses 
were conducted using IBM SPSS Statistics 23.
3 RESULTS
The study initially involved 1,526 students, with 614 
students participating in the subsequent stage. Women 
comprised the majority in both stages, representing 72.0% 
and 74.4% of the participants, respectively (Table 1).
Characteristics of the study samples.
Total n (%)Romania n (%)Bulgaria n (%) Serbia n (%)Moldova n (%)Albania n (%)Characteristics
Table 1.
2015/2016 
Gender 
Men 
Women
Year of study 
First 
Final
Total
Age (years, M±SD)
2020/2021
Gender 
Men 
Women
Total
Age (years, M±SD)
 
427 (28.0) 
1099 (72.0)
 
860 (56.4) 
666 (43.6)
1526 (100.0)
21.5±2.8
 
157 (25.6) 
457 (74.4)
614 (100.0)
24.8±1.7
 
127 (31.9) 
271 (68.1)
 
207 (52.0) 
191 (48.0)
398 (100.0)
21.8±2.9
 
40 (19.7) 
163 (80.3)
203 (100.0)
24.9±1.4
 
68 (28.0) 
175 (72.0)
 
111 (45.7) 
132 (54.3)
243 (100.0)
22.2±3.2
 
45 (44.6) 
56 (55.4)
101 (100.0)
24.1±2.0
 
106 (31.6) 
229 (68.4)
 
187 (55.8) 
148 (44.2)
335 (100.0)
21.3±2.5
 
27 (25.2) 
80 (74.8)
107 (100.0)
25.3±1.7
 
74 (23.6) 
240 (76.4)
 
229 (72.9) 
85 (27.1)
314 (100.0)
20.8±2.6
 
24 (27.0) 
65 (73.0)
89 (100.0)
25.0±2.0
 
52 (22.0) 
184 (78.0)
 
126 (53.4) 
110 (46.6)
236 (100.0)
21.5±2.7
 
21 (18.4) 
93 (81.6)
114 (100.0)
24.3±1.6
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191
In the first stage, the average MICA-2 score for first-
year students across all countries was 50.6, while for 
final-year students it was 49.1. In the second stage, the 
average score decreased to 45.6. Significant gender-based 
differences were found in Serbia in the second stage, with 
female scores being significantly lower than male scores 
(34.5 vs. 39.2; p=0.007). During the first stage, significant 
differences between first and final-year students were 
observed in Albania, Bulgaria and Romania. When 
comparing MICA-2 scores between first-year students 
in 2015/2016 and those in their final year in 2020/2021, 
significant differences were detected in all countries 
except Albania (Table 2).
In the first stage, the average AQ-9 score for first-year 
students across all countries was 35.2, compared to 35.0 
for final-year students. In the second stage, the average 
score was 32.7. Regarding gender, a significant difference 
was observed among Moldovan students in their final year 
of 2015/2016 (p=0.011), which was not observed in other 
countries. Analysis by research year revealed that final-
year students had lower AQ-9 scores compared to first-year 
students in Albania (p<0.05) and Bulgaria (p<0.001) during 
the first stage. Conversely, Moldovan final-year students 
had significantly higher scores in the first stage (p<0.001). 
Additionally, a comparison between AQ-9 scores of first-
year students in 2015/2016 and those who completed 
a psychiatry course in 2020/2021 showed a significant 
decrease in Bulgaria (from 42.1 to 33.2, p<0.001) and 
Romania (from 37.1 to 33.1, p<0.001) (Table 2).
AQ-9 and MICA-2 scores measured among medical students.
AQ-9 MICA-2
M MSD SDp * p *
Characteristics
Table 2.
Albania
First year (2015/2016)
Men
Women
Final year (2015/2016)
Men
Women
Final year (2020/2021)
Men
Women
First year (2015/2016)
Final year (2015/2016)
First year (2015/2016)
Final year (2020/2021)
Bulgaria
First year (2015/2016)
Men
Women
Final year (2015/2016)
Men
Women
Final year (2020/2021)
Men
Women
First year (2015/2016)
Final year (2015/2016)
First year (2015/2016)
Final year (2020/2021)
Moldova
First year (2015/2016)
Men
Women
Final year (2015/2016)
Men
 
32.6
34.3
30.2
31.2
33.8
32.9
33.9
31.0
33.9
33.1
42.4
42.0
35.8
37.0
32.3
33.9
42.1
36.6
42.1
33.2
35.5
34.4
34.3
54.5
55.3
52.3
52.8
54.7
54.1
55.1
52.7
55.1
54.2
59.2
59.0
57.5
55.8
50.6
52.3
59.1
56.5
59.1
51.5
52.9
51.6
52.2
 
10.4
10.0
8.8
9.4
9.8
11.2
10.1
9.2
10.1
10.9
10.8
10.0
7.3
8.4
8.2
9.2
10.1
8.0
10.1
8.7
10.6
9.5
12.8
6.1
5.1
6.3
6.0
4.5
5.5
5.4
6.0
5.4
5.3
7.0
9.0
8.7
5.5
7.4
7.6
8.7
6.9
8.7
7.5
6.4
6.1
5.2
0.440
0.668
0.727
0.022
0.550
0.888
0.393
0.352
<0.001
<0.001
0.477
0.011
0.485
0.714
0.645
<0.001
0.187
0.929
0.179
0.288
0.010
<0.001
0.181
0.682
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192
*p-Independent samples t-test
AQ-9 MICA-2
M MSD SDp * p *
Characteristics
Women
Final year (2020/2021)
Men
Women
First year (2015/2016)
Final year (2015/2016)
First year (2015/2016)
Last year (2020/2021)
Romania
First year (2015/2016)
Men
Women
Final year (2015/2016)
Men
Women
Final year (2020/2021)
Men
Women
First year (2015/2016)
Final year (2015/2016)
First year (2015/2016)
Final year (2020/2021)
Serbia
First year (2015/2016)
Men
Women
Final year (2015/2016)
Men
Women
Final year (2020/2021)
Men
Women
First year (2015/2016)
Final year (2015/2016)
First year (2015/2016)
Final year (2020/2021)
41.7
32.7
35.9
34.7
39.8
34.7
35.0
36.9
37.3
37.5
37.8
34.1
32.9
37.1
37.7
37.1
33.1
32.3
29.6
28.6
31.2
31.4
28.6
30.5
30.4
30.5
29.3
51.7
43.8
47.8
51.9
51.8
51.9
46.7
52.2
50.1
47.4
46.9
43.7
42.4
50.8
47.0
50.8
42.7
41.7
40.1
41.1
41.0
39.2
34.5
40.6
41.0
40.6
35.7
11.0
11.1
12.0
9.8
11.9
9.8
11.8
9.4
9.1
11.0
10.5
10.9
10.4
9.2
10.6
9.2
10.5
8.1
9.6
7.0
9.3
9.9
7.1
9.2
8.6
9.2
8.0
5.2
11.5
9.6
6.2
5.2
6.2
10.2
8.4
9.0
9.5
8.3
7.2
6.5
8.9
8.7
8.9
6.7
7.8
6.7
5.7
7.8
10.4
6.5
7.0
7.2
7.0
7.8
0.259
<0.001
0.787
0.805
0.850
0.517
0.550
<0.001
0.058
0.092
0.108
0.924
0.280
0.101
0.887
<0.001
0.100
0.703
0.292
<0.001
<0.001
0.148
0.921
0.007
0.589
<0.001
Analysis of AQ-9 scores across different academic years 
and countries indicated significant differences (p<0.05) 
between study stages. Notably, the highest stigma levels, 
as measured by AQ-9, were observed among first-year 
students in Bulgaria (42.1), whereas the lowest score 
was found among final-year students in Serbia during the 
2020/2021 academic year (29.3) (Table 3).
Comparative analysis of average MICA-2 scores across 
countries revealed significant differences in both research 
stages (p<0.001). Initially, Bulgarian first-year students had 
the highest score (59.1), while in the subsequent stage, 
the highest score was observed among Albanian students 
(54.2). In both research stages, the lowest MICA-2 scores 
were observed in Serbia (Table 3).
10.2478/sjph-2024-0025 Zdr Varst. 2024;63(4):188-197
193
AQ-9 and MICA-2 scores between countries.
Association between gender, year of study, country and AQ-9/MICA-2 scores in the first stage of the research.
Association between gender, year of study, country 
and AQ-9/MICA-2 scores in the first stage of the 
research (logistic regression—unadjusted OR).
* p-Logistic Regression
* p-Chi-Square Test
* p-ANOVA
Albania
AQ-9 Score MICA-2 Score
MoldovaBulgaria Romania Serbia
M
Low
AQ-9 Score MICA-2 Score
LowHigh High
n
OR 
(95% CI)
OR 
(95% CI)
nn n
p *
MM M MSD
%
p p
%% %p p
SDSD SD SD
Year of Study
Year of Study
Year  
of Study
Table 3.
Table 4.
Table 5.
AQ—9
2015/2016 
2020/2021
Gender 
Men 
Women
Year of study 
First 
Final
Country 
Albania 
Bulgaria 
Moldova 
Romania 
Serbia
Gender 
Men 
Women
Year of study 
First year 
Final year
Country 
Serbia 
Albania 
Bulgaria 
Moldova 
Romania
MICA—2
2015/2016 
2020/2021
First 
Final
Final
First 
Final
Final
33.9 
31.0
33.1
 
244 
563
 
453 
354
 
149 
92 
158 
173 
235
 
1 
1.3 (1.0–1.6)
 
1 
1.0 (0.8–1.2)
 
1 
1.4 (1.0–2.0) 
3.9 (2.7–5.5) 
2.3 (1.7–3.2) 
3.1 (2.2–4.2)
  
1 
1.1 (0.9–1.4)
 
1 
0.8 (0.6–1.0)
 
1 
35.2 (21.6–57.5) 
75.0 (43.7–128.7) 
14.7 (9.4–23.0) 
9.1 (5.9–14.0)
 
238 
582
 
444 
376
 
74 
39 
155 
239 
313
 
183 
536
 
407 
312
 
87 
151 
156 
225 
100
 
189 
517
 
416 
290
 
162 
204 
159 
159 
22
55.1 
52.7
54.2
<0.001 
<0.001
0.002
<0.001 
<0.001
<0.001
34.7 
39.8
35.0
51.9 
51.8
46.7
42.1 
36.6
33.2
59.1 
56.5
51.5
37.1 
37.7
33.1
50.8 
47.0
42.7
30.5 
30.4
29.3
40.6 
41.0
35.7
10.1 
9.2
10.9
 
57.1 
51.2
 
52.7 
53.2
 
63.1 
37.9 
50.3 
43.5 
70.1
 
 
0.037
 
 
0.853 
 
0.079 
<0.0001 
<0.0001 
<0.0001
 
 
0.291
 
 
0.021
 
 
<0.0001 
<0.0001 
<0.0001 
<0.0001
 
55.7 
53.0
 
51.6 
56.5
 
31.4 
16.0 
49.4 
60.1 
93.4
 
42.9 
48.8
 
47.3 
46.8
 
36.9 
62.1 
49.7 
56.5 
29.9
 
44.3 
47.0
 
48.4 
43.5
 
68.6 
84.0 
50.6 
39.9 
6.6
 
0.040 
 
0.877 
 
<0.001
 
0.332 
 
0.063 
 
<0.001
5.4 
6.0
5.3
9.8 
11.9
11.8
6.2 
5.2
10.2
10.1 
8.0
8.7
8.7 
7.0
7.5
9.2 
10.6
10.5
8.9 
8.7
6.7
9.2 
8.6
8.0
7.0 
7.2
7.8
Univariate analysis revealed that men had a higher 
prevalence of low AQ-9 scores (57.1%) compared to women 
(51.2%). Bulgarian students had the highest prevalence 
of AQ-9 scores above the median (62.1%), while Serbian 
students had the lowest (29.9%). Significant differences 
were observed in the prevalence of both low and high 
AQ-9 and MICA-2 scores between countries (Table 4).
The logistic regression analysis showed significant findings. 
Women had higher AQ-9 scores than men, with a significant 
crude odds ratio (OR=1.3, p=0.037). Final-year students 
had notably lower odds for high MICA-2 scores compared 
to first-year students (OR=0.8, p=0.021) (Table 5).
The multivariable regression analysis confirmed that 
female students were 30% more likely to have elevated 
AQ-9 scores compared to male students (p=0.029). 
However, no significant association was found between 
gender and MICA-2 scores. Completing psychiatry courses 
was associated with a 30% reduced likelihood of higher 
MICA-2 scores compared to first-year students (Table 6).
10.2478/sjph-2024-0025 Zdr Varst. 2024;63(4):188-197
194
Association between gender, year of study, country 
and AQ-9/MICA-2 scores in the first stage of the 
research (logistic regression—adjusted OR).
AQ-9 Score MICA-2 Score
AOR (95% CI) AOR (95% CI)p p
Year of Study
Table 6.
Gender 
Men 
Women
Year of study 
First year 
Final year
Country 
Serbia 
Albania 
Bulgaria 
Moldova 
Romania
  
1 
1.3 (1.0–1.6)
 
1 
1.0 (0.8–1.2)
 
1 
1.3 (0.9–1.9) 
3.9 (2.7–5.5) 
2.3 (1.6–3.1) 
3.1 (2.3–4.2)
  
1 
1.0 (0.7–1.3)
 
1 
0.7 (0.5–0.9)
 
1 
32.3 (19.3–54.1) 
79.8 (45.8–139.2) 
13.9 (8.5–22.6) 
9.7 (6.0–15.7)
 
 
0.029 
 
0.657 
 
0.104 
<0.001 
<0.001 
<0.001
 
 
0.805
 
 
0.002
 
 
<0.001 
<0.001 
<0.001 
<0.001
4 DISCUSSION
The level of stigmatising attitudes measured among first-
year medical students was not as high as expected (16, 
25, 33), aligning with recent research findings from South 
Africa (34). Across all countries, the mean AQ-9 score for 
first-year students was 35.2, while in the second stage, 
the average score among final-year students decreased to 
32.7, which is similar to a Portuguese study, where the 
AQ-9 score was 33.6 (35).
No significant difference in AQ-9 scores between genders 
was found across countries (except in Moldova), aligning 
with one previous study (35) but contradicting other 
studies that indicated lower stigma levels among female 
medical students (36-37). However, multivariable analysis 
of the initial stage revealed a higher likelihood for female 
students to show more pronounced stigmatising attitudes 
than their male counterparts, which was unexpected. One 
possible explanation for this difference is that females 
experience more internalised stigma compared to men 
(38), potentially leading to higher stigmatising attitudes 
toward others. Another factor could be that females are 
more likely to acknowledge and report psychological 
distress (39), which might result in a less positive 
attitude toward mental illnesses. Future research should 
explore these potential factors to better understand the 
underlying reasons for gender differences in stigmatising 
attitudes across countries involved in the study.
The average MICA-2 score for first-year students across 
all countries in the first stage of the study was 50.6, 
while for final-year students in the second stage, it was 
45.6, indicating a significant difference. Several studies 
reported lower average MICA-2 scores compared to our 
findings. In Malaysia, the average score was 43.4 (40), 
while in Portugal, it ranged from 38.2 to 36.7 before and 
after psychiatry and psychology courses (41). An Australian 
study showed an average score of 36.8 (42), while in India 
the average MICA-2 score was 42.4 (43). A study comparing 
various programmes in Spain and Chile found a MICA score 
of 40.2 among medical students, who exhibited more 
negative attitudes towards mental disorders compared to 
students in nursing, psychology, and occupational therapy 
programmes (44). Medical schools in Poland recorded 
a score of 41.1, with no significant difference based on 
psychiatry attendance (45).
In our study, Bulgarian students had the highest average 
MICA-2 score in the first stage, regardless of their year of 
study, while students from Albania recorded the highest 
average score in the second stage. The most substantial 
decrease in MICA-2 score between stages was observed in 
Romania (from 50.8 to 42.7). Multivariable analysis showed 
that final-year students had a significantly lower likelihood 
of having higher MICA-2 scores compared to first-year 
students (OR=0.7), which is similar to an Australian study, 
where the baseline MICA-2 score was 48.2 and decreased 
to 43.5 after psychiatry classes (20). Other studies also 
support this, indicating that increased knowledge and 
exposure to patients with mental disorders positively 
affect stigma levels (22, 40, 41).
Furthermore, existing literature suggests that educational 
interventions aim to foster positive shifts in medical 
students’ attitudes toward psychiatry, indicating that 
clerkships generally have a beneficial impact on students’ 
attitudes in this field. This shift in attitude is evidenced by 
an increasing perception among students of psychiatry as 
a scientifically growing area of medicine, with significant 
effectiveness in psychiatric treatments (46).
In contrast to our findings, research conducted among 
medical university students in 65 countries worldwide 
reported an average MICA-2 score of 40.5, with no 
statistically significant difference based on attendance in 
psychiatry lectures (47).
Regarding gender, a significant difference in MICA-2 score 
was observed only in Serbia during the second stage of 
our research, with males exhibiting higher scores than 
females. Some studies confirm more stigmatising attitudes 
among men (43, 44), others report no significant gender 
differences (40, 41), while in Australia female students 
had higher scores compared to males (42).
Based on our findings and the existing literature, future 
research on stigmatising attitudes among healthcare 
professionals, particularly medical students, should 
explore several key areas: longitudinal comparative 
studies, examining attitude shifts across various stages 
of medical education and within different geographical 
and educational settings, as well as the inclusion of 
more variables that might influence student attitudes. 
Additionally, our study suggests that psychiatric training 
during medical school has a noticeable positive influence 
on attitudes, an effect that could be further enhanced by 
incorporating specific lectures focused on stigma into the 
curriculum. 
4.1 Limitations of the study
The selection of medical faculties was based on established 
research collaborations, which may not represent the 
overall student population in these five countries, thereby 
limiting the generalisability of the results. The relatively 
low response rates, particularly in Albania and Moldova, 
could be attributed to the strictly voluntary nature of our 
study, cultural differences and external factors such as 
COVID-19 restrictions. These response rates may affect the 
sample’s representativeness, potentially introducing bias 
if respondents differ from non-respondents. Due to data 
collection constraints, we were unable to conduct a non-
respondent analysis. These limitations highlight the need for 
future research on a larger and more representative sample.
Variations in the psychiatry curriculum, including the 
timing of students’ attendance of psychiatry classes, led 
to differing intervals between psychiatry rotations and 
data collection periods. The preservation of anonymity 
prevented more detailed correlation analyses between 
first-year students from the initial stage and students from 
the subsequent stage of the research. Another limitation 
of our study is the potential bias introduced by self-report 
measures, such as social desirability and subjective 
interpretation. In order to reduce this bias, we used valid 
instruments with good internal consistency, provided 
clear instructions to participants and ensured anonymity.
One factor that could potentially influence the results of 
the study is the different modes of data collection used 
in the two study stages (mode effect). In the first stage 
we used printed questionnaires, while the second stage 
employed an online survey method due to the COVID-19 
pandemic restrictions. If the second stage of the research 
had been postponed to maintain consistency in the survey 
method, the students who were in their first year during 
the initial stage of the research would have been missed.
The hybrid nature of psychiatry classes during the 
COVID-19 pandemic might have affected the quality and 
scope of the classes, as well as contact with patients, 
potentially impacting the level of stigma among students 
in the second stage of the research.
While our study provides insights into stigmatising 
attitudes among medical students from five South-Eastern 
European countries, future research could include broader 
populations of other future healthcare professionals (e.g. 
dentists, pharmacists, nurses) or different settings to 
enhance the generalisability of the results.
5 CONCLUSIONS
Our study revealed significant differences in stigmatising 
attitudes towards individuals with mental health conditions 
among medical students from the five countries involved. 
Despite initially high levels of stigma, psychiatry clerkships 
generally had a positive impact, improving attitudes 
towards individuals with mental health conditions. 
Early recognition of existing stigmatising attitudes and 
intervention during medical education can help develop 
strategies to reduce stigma, fostering compassionate and 
informed care. Further research is crucial for analysing 
and comparing psychiatry curriculum content across these 
countries and for identifying areas for reducing stigma 
among medical students, including the introduction of 
tailored training programmes to address this issue. 
CONFLICTS OF INTEREST
The author(s) declared no potential conflicts of interest 
with respect to the research, authorship and/or publication 
of this article.
FUNDING
The authors received no financial support for the research, 
authorship and/or publication of this article.
ETHICS APPROVAL
This study was approved by the Committee of Ethics and 
Academic and Scientific Deontology of the University of 
Medicine and Pharmacy of Craiova, Romania (approval no. 
15) on February 26, 2016. This research was conducted 
ethically in accordance with the World Medical Association 
Declaration of Helsinki.
AVAILABILITY OF DATA AND MATERIALS
All data and materials used in this study are available 
upon reasonable request.
195
10.2478/sjph-2024-0025 Zdr Varst. 2024;63(4):188-197
ORCID
Sanja Harhaji: 
https://orcid.org/0000-0003-0561-6077
Sonila Tomori: 
https://orcid.org/0000-0001-6451-9088
Vladimir Nakov: 
https://orcid.org/0000-0003-0730-9898
Jana Chihai: 
https://orcid.org/0000-0002-7720-5544
Ivana Radić: 
https://orcid.org/0000-0003-1889-2978
Tedi Mana: 
https://orcid.org/0000-0002-3723-675X
Kaloyan Stoichev: 
https://orcid.org/0000-0001-7903-2387
Andrei Esanu: 
https://orcid.org/0000-0003-1289-4622
Mihail Cristian Pirlog: 
https://orcid.org/0000-0002-3890-0931
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