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      Perspectives of healthcare providers, service users, and family members about mental illness stigma in primary care settings: A multi-site qualitative study of seven countries in Africa, Asia, and Europe

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          Abstract

          Background

          Stigma among healthcare providers is a barrier to the effective delivery of mental health services in primary care. Few studies have been conducted in primary care settings comparing the attitudes of healthcare providers and experiences of people with mental illness who are service users in those facilities. Such research is necessary across diverse global settings to characterize stigma and inform effective stigma reduction.

          Methods

          Qualitative research was conducted on mental illness stigma in primary care settings in one low-income country (Nepal), two lower-middle income countries (India, Tunisia), one upper-middle-income country (Lebanon), and three high-income countries (Czech Republic, Hungary, Italy). Qualitative interviews were conducted with 248 participants: 64 primary care providers, 11 primary care facility managers, 111 people with mental illness, and 60 family members of people with mental illness. Data were analyzed using framework analysis.

          Results

          Primary care providers endorsed some willingness to help persons with mental illness but reported not having appropriate training and supervision to deliver mental healthcare. They expressed that people with mental illness are aggressive and unpredictable. Some reported that mental illness is incurable, and mental healthcare is burdensome and leads to burnout. They preferred mental healthcare to be delivered by specialists. Service users did not report high levels of discrimination from primary care providers; however, they had limited expectations of support from primary care providers. Service users reported internalized stigma and discrimination from family and community members. Providers and service users reported unreliable psychiatric medication supply and lack of facilities for confidential consultations. Limitations of the study include conducting qualitative interviews in clinical settings and reliance on clinician-researchers in some sites to conduct interviews, which potentially biases respondents to present attitudes and experiences about primary care services in a positive manner.

          Conclusions

          Primary care providers’ willingness to interact with people with mental illness and receive more training presents an opportunity to address stigmatizing beliefs and stereotypes. This study also raises important methodological questions about the most appropriate strategies to accurately understand attitudes and experiences of people with mental illness. Recommendations are provided for future qualitative research about stigma, such as qualitative interviewing by non-clinical personnel, involving non-clinical staff for recruitment of participants, conducting interviews in non-clinical settings, and partnering with people with mental illness to facilitate qualitative data collection and analysis.

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          Most cited references39

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          Evidence for effective interventions to reduce mental-health-related stigma and discrimination.

          Stigma and discrimination in relation to mental illnesses have been described as having worse consequences than the conditions themselves. Most medical literature in this area of research has been descriptive and has focused on attitudes towards people with mental illness rather than on interventions to reduce stigma. In this narrative Review, we summarise what is known globally from published systematic reviews and primary data on effective interventions intended to reduce mental-illness-related stigma or discrimination. The main findings emerging from this narrative overview are that: (1) at the population level there is a fairly consistent pattern of short-term benefits for positive attitude change, and some lesser evidence for knowledge improvement; (2) for people with mental illness, some group-level anti-stigma inventions show promise and merit further assessment; (3) for specific target groups, such as students, social-contact-based interventions usually achieve short-term (but less clearly long-term) attitudinal improvements, and less often produce knowledge gains; (4) this is a heterogeneous field of study with few strong study designs with large sample sizes; (5) research from low-income and middle-income countries is conspicuous by its relative absence; (6) caution needs to be exercised in not overgeneralising lessons from one target group to another; (7) there is a clear need for studies with longer-term follow-up to assess whether initial gains are sustained or attenuated, and whether booster doses of the intervention are needed to maintain progress; (8) few studies in any part of the world have focused on either the service user's perspective of stigma and discrimination or on the behaviour domain of behavioural change, either by people with or without mental illness in the complex processes of stigmatisation. We found that social contact is the most effective type of intervention to improve stigma-related knowledge and attitudes in the short term. However, the evidence for longer-term benefit of such social contact to reduce stigma is weak. In view of the magnitude of challenges that result from mental health stigma and discrimination, a concerted effort is needed to fund methodologically strong research that will provide robust evidence to support decisions on investment in interventions to reduce stigma.
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            Stigma in health facilities: why it matters and how we can change it

            Stigma in health facilities undermines diagnosis, treatment, and successful health outcomes. Addressing stigma is fundamental to delivering quality healthcare and achieving optimal health. This correspondence article seeks to assess how developments over the past 5 years have contributed to the state of programmatic knowledge—both approaches and methods—regarding interventions to reduce stigma in health facilities, and explores the potential to concurrently address multiple health condition stigmas. It is supported by findings from a systematic review of published articles indexed in PubMed, Psychinfo and Web of Science, and in the United States Agency for International Development’s Development Experience Clearinghouse, which was conducted in February 2018 and restricted to the past 5 years. Forty-two studies met inclusion criteria and provided insight on interventions to reduce HIV, mental illness, or substance abuse stigma. Multiple common approaches to address stigma in health facilities emerged, which were implemented in a variety of ways. The literature search identified key gaps including a dearth of stigma reduction interventions in health facilities that focus on tuberculosis, diabetes, leprosy, or cancer; target multiple cadres of staff or multiple ecological levels; leverage interactive technology; or address stigma experienced by health workers. Preliminary results from ongoing innovative responses to these gaps are also described. The current evidence base of stigma reduction in health facilities provides a solid foundation to develop and implement interventions. However, gaps exist and merit further work. Future investment in health facility stigma reduction should prioritize the involvement of clients living with the stigmatized condition or behavior and health workers living with stigmatized conditions and should address both individual and structural level stigma.
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              Mental health-related stigma in health care and mental health-care settings.

              This Review considers the evidence for mental-health-related stigma in health-care and mental-health-care settings. Do mental-health-care and other health-care professionals stigmatise people using their services? If so, what are the effects on quality of mental and physical health care? How can stigma and discrimination in the context of health care be reduced? We show that the contact mental-health-care professionals have with people with mental illness is associated with positive attitudes about civil rights, but does not reduce stigma as does social contact such as with friends or family members with mental illness. Some evidence suggests educational interventions are effective in decreasing stigma especially for general health-care professionals with little or no formal mental health training. Intervention studies are needed to underpin policy; for instance, to decrease disparity in mortality associated with poor access to physical health care for people with mental illness compared with people without mental illness.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: Writing – original draft
                Role: Formal analysisRole: Writing – original draft
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Project administrationRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: SupervisionRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: SupervisionRole: Writing – review & editing
                Role: Formal analysisRole: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: InvestigationRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Formal analysisRole: Writing – review & editing
                Role: Formal analysisRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: Writing – review & editing
                Role: ConceptualizationRole: MethodologyRole: Writing – review & editing
                Role: ConceptualizationRole: SupervisionRole: Writing – review & editing
                Role: ConceptualizationRole: Formal analysisRole: MethodologyRole: SupervisionRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS One
                plos
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                27 October 2021
                2021
                : 16
                : 10
                : e0258729
                Affiliations
                [1 ] Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
                [2 ] Department for Psychiatry II, Ulm University and BKH Günzburg, Günzburg, Germany
                [3 ] Department of Psychiatry A, Razi Hospital La Manouba, Manouba, Tunisia
                [4 ] Faculty of Medicine of Tunis, University of Tunis El Manar, Tunis, Tunisia
                [5 ] Department of Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Bengaluru, India
                [6 ] Department of Epidemiology, Centre for Public Health, National Institute of Mental Health and Neurosciences, Bengaluru, India
                [7 ] Transcultural Psychosocial Organization Nepal, Kathmandu, Nepal
                [8 ] Department of Public Mental Health, National Institute of Mental Health, Klecany, Czechia
                [9 ] Unit of Psychiatry, IRCCS Istituto Centro San Giovanni di Dio Fatebenefratelli, Brescia, Italy
                [10 ] Section of Psychiatry, Department of Neuroscience, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
                [11 ] Awakenings Foundation Budapest, Budapest, Hungary
                [12 ] Department of Mental Health, Alto Garda e Ledro Giudicarie, Arco, Italy
                [13 ] National Mental Health Programme Ministry of Public Health, Beirut, Lebanon
                [14 ] Department of Psychiatry, Saint Joseph University, Beirut, Lebanon
                [15 ] Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit, Amsterdam, The Netherlands
                [16 ] Institute of Psychology, University of Lausanne, Lausanne, Switzerland
                [17 ] Department of Psychology, University of Zurich, Zurich, Switzerland
                [18 ] Implemental Worldwide, London, United Kingdom
                [19 ] Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
                [20 ] Institute of Population Health Sciences, University of Liverpool, Liverpool, United Kingdom
                [21 ] Division of Global Mental Health, Department of Psychiatry, George Washington University, Washington, DC, United States of America
                National Health Laboratory Service, SOUTH AFRICA
                Author notes

                Competing Interests: The authors have declared no competing interests.

                Author information
                https://orcid.org/0000-0003-0239-6208
                https://orcid.org/0000-0003-2343-9684
                https://orcid.org/0000-0003-1087-0379
                https://orcid.org/0000-0001-9973-5418
                https://orcid.org/0000-0001-7434-7451
                https://orcid.org/0000-0002-6798-8178
                https://orcid.org/0000-0002-3829-4820
                Article
                PONE-D-21-04968
                10.1371/journal.pone.0258729
                8550394
                34705846
                6bb9e3ae-5584-42c2-ab6c-306334ddfa07
                © 2021 Koschorke et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 13 February 2021
                : 1 October 2021
                Page count
                Figures: 0, Tables: 3, Pages: 29
                Funding
                Funded by: NIMHANS
                Award ID: NIMH/ PROF/ AVC/00571/2017-18
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000025, National Institute of Mental Health;
                Award ID: K01MH104310
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000025, National Institute of Mental Health;
                Award ID: R21MH111280
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000025, National Institute of Mental Health;
                Award ID: R01MH100470
                Award Recipient :
                Funded by: Medical Research Council (UK)
                Award ID: MR/S001255/1
                Award Recipient :
                Funded by: Medical Research Council (UK)
                Award ID: MR/R023697/1
                Award Recipient :
                Funded by: NIHR Asset Global Health Unit
                Award Recipient :
                Funded by: NIHR Applied Research Collaboration South London at King’s College London NHS Foundation Trust
                Award Recipient :
                No funding was provided for the research design, implementation, and analyses described in this manuscript, with the exception of an intramural grant from NIMHANS for the research conducted in Bengaluru, India (Project code: NIMH/ PROF/ AVC/00571/2017-18, PI: AV Cherian) and funding from Médecins du Monde to the National Mental Health Programme in Lebanon. DG and BAK have received funding from the US National Institute of Mental Health (K01MH104310; R21MH111280). GT is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration South London at King’s College London NHS Foundation Trust, and by the NIHR Asset Global Health Unit award. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care. GT also receives support from the National Institute of Mental Health of the National Institutes of Health under award number R01MH100470 (Cobalt study). GT is supported by the UK Medical Research Council in relation the Emilia (MR/S001255/1) and Indigo Partnership (MR/R023697/1) awards.
                Categories
                Research Article
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Medicine and Health Sciences
                Health Care
                Primary Care
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Mental Health Therapies
                Medicine and Health Sciences
                Health Care
                Health Care Providers
                Medicine and Health Sciences
                Health Care
                Health Care Facilities
                Medicine and Health Sciences
                Health Care
                Health Care Providers
                Physicians
                People and Places
                Population Groupings
                Professions
                Medical Personnel
                Physicians
                Social Sciences
                Sociology
                Human Families
                People and Places
                Population Groupings
                Professions
                Medical Personnel
                Nurses
                Medicine and Health Sciences
                Health Care
                Health Care Providers
                Nurses
                Custom metadata
                Because each of the countries has a different consent process and national ethical board standard, not all qualitative transcripts can be shared publicly. In addition, some countries have small sample sizes that make anonymization not possible because the identity of the respondents could be determined based on characteristics of the quotes and site details. Moreover, given the nature of stigma and risks of identity disclosure, this information is particularly sensitive for service users and caregivers. Therefore, we encourage interested parties to obtain ethical approval from all of the relevant ethical review boards to access the qualitative data. Ethical review board information Umbrella review from King’s College London PNM Research Ethics Subcommittee, King’s College, London (Reference Number (No.) RESCMR-17/18-4109; approval date 23 February 2017) Contact email address: james.2.patterson@ 123456kcl.ac.uk Czech Republic National Institute of Mental Health, Klecany, Czechia. (No 128/17, 19.4.2017), Contact email address: olga.svecova@ 123456nudz.cz and martin.bares@ 123456nudz.cz Hungary Semmelweis Egyetem Regionális, Intézményi Tudományos és Kutatásetikai Bizottság, (No. SE TUKEB 162/2017) Contact email address: titkarsag.kutatasetikaibizottsag@ 123456semmelweis-univ.hu India NIMHANS Institutional Review Board, Ref No: NIMHANS/IEC(BEH.SC.DIV.) 7th MEETING/2017; and permission from Directorate of Health Family Welfare Servicers, Government of Karnataka, India, (No. DD/Mental Health/10/18-19 dated 26.04.2018), Contact email address: deannimhans@ 123456yahoo.com and dd6mhkar@ 123456gmail.com Italy Comitato Etico IRCCS San Giovanni di Dio – Fatebenefratelli, Brescia, (No. 102/2017); Ethics Committee of the Provinces of Verona and Rovigo, (No. 44066, 13 September 2017) Contact email address: comitatoetico.veronarovigo@ 123456aovr.veneto.it and ceioc@ 123456fatebenefratelli.eu Lebanon Saint Joseph’s University Beirut, (No. CEHDF 1193; 3 July 2018) Contact email address: cue@ 123456usj.edu.lb and virginia.elkhoury@ 123456usj.edu.lb Nepal Nepal Health Research Council, (No. 139/2016, 28 July 2016), Contact email address: nhrc@ 123456nhrc.gov.np Tunisia Ethics Committee of Razi Hospital La Manouba, (No. RPA 2/2017, 28 January 2017). Contact email address: amina.gargouri-berrechid@ 123456fmt.utm.tn .

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