Exploring stigma, discrimination, and recovery-based perspectives

In brief

Stigma and discrimination can take place anywhere, including in health care settings. Stigma is a critical barrier to high-quality health care for people living with mental illness and substance use problems. This makes it an urgent and complex public health issue.

“Exploring Stigma, Discrimination, and Recovery-based Perspectives Toward Mental Illness and Substance Use Problems Among Primary Healthcare Providers Across Ontario” is an anti- stigma study that aims to test the effectiveness of a new, evidence-based, anti-stigma and pro-recovery intervention among primary health care providers who work with individuals affected by mental illness and substance use problems. The study will also test the feasibility of delivering the intervention to organizations in Toronto.

The goal of the study is to determine if the intervention can change service providers’ attitudes and behaviours towards people with mental health and addictions problems. It will also evaluate if clients believe stigma has been reduced or eliminated within the participating community health centres.

In this edition of Research As It Happens, EENet’s Angela Yip describes the research project. Read it below or access the PDF.

Research As It Happens highlights evidence as it is being generated.

About this program

Emily Lentinello, Project Coordinator and participating Community Health Centres participating in the randomization selection.
Emily Lentinello, Project Coordinator and participating Community Health Centres participating in the randomization selection. 

Stigma and discrimination takes place everywhere, including in health care settings. Stigma is a critical barrier to high-quality health care for people suffering from mental illness and substance use problems. This makes it an urgent and complex public health issue.  

Individuals with mental health or addiction issues can experience stigma in different ways, including: 

  • Structural stigma –through the promotion of negative messages by institutions, such as a newspaper or TV stations. 
  • Public stigma - attitudes that the general population may have towards people with mental illness and addictions issues. And,
  • Self stigma - as a result of one’s own negative belief about themselves that cause them to feel embarrassment or self-loathing. 

All of these different types of stigma play a role in developing and reinforcing negative thoughts and attitudes towards those with mental health and addictions issues. The stigmatizing messages and attitudes also often translate into discriminatory behaviour towards people with mental health or addiction issues. 

What is the research about?

‘Exploring Stigma, Discrimination, and Recovery-Based Perspectives Toward Mental Illness and Substance Use Problems Among Primary Healthcare Providers Across Ontario’ is an anti-stigma study that aims to evaluate the effectiveness of an anti-stigma intervention in community health centres (CHCs) in the Greater Toronto Area. The main objective of the project, funded by the Canadian Institutes of Health Research (CIHR), is to reduce stigmatizing attitudes and behaviours among primary health care providers. 

This project stems from an earlier project titled “Preventing Mental Illness and Substance Use-Related Stigma & Discrimination and Promoting Recovery-Oriented Practices in Primary Health Care in Ontario”, funded by the Development and Dissemination Fund at Centre for Addiction and Mental Health (CAMH) and the Mental Health Commission of Canada. The purpose of this project was to design and pilot test an anti-stigma, pro-recovery and anti-discrimination intervention among primary care providers in CHCs in Ontario that serve African, Caribbean and Latin American immigrants.  

This new CIHR phase will utilize a clustered randomized control trial to test the effectiveness of the newly developed, evidence-based anti-stigma and pro-recovery intervention among primary health care providers who work with individuals affected by mental illness and substance use problems. It will also test the feasibility of delivering the intervention to organizations. The goal is to determine if the intervention can change service providers’ attitudes and behaviours towards people with mental health and addictions problems. The study will also evaluate client’s perceptions of stigma, to see if they believe stigma has been reduced or eliminated within the participating CHCs.  

This is the first study in Canada to evaluate a comprehensive anti-stigma and pro-recovery intervention targeting primary health care providers from an organizational perspective, in a randomized, controlled study (often believed to be the gold standard of research).

Who is conducting the research? 

The co-principal investigators are Akwatu Khenti, Director of the Office of Transformative Global Health at CAMH, in Toronto, and Dr. Patrick Corrigan, Distinguished Professor and Associate Dean for Research in the College of Psychology at the Illinois Institute of Technology, in Chicago. CAMH co-applicants involved include Dr. Robert Mann, Dr. Branka Agic, Dr. Hayley Hamilton, Dr. Jaime Sapag, and Sireesha Bobbili. Other co-applicants include Dr. Heather Stuart, professor of Community Health and Epidemiology in the Faculty of Health Sciences at Queen’s University, in Kingston, and Dr. Scott Patten, from the Community Health Sciences Department at the University of Calgary. 

What is the target population?

The research team hopes to include 250 clients in the study. They will include clients who are 16 years or older who:

  • Indicate that they currently experience and/or have experienced mental illness and/or substance use problems in the last 12 months, and 
  • Indicate they have received any type of care/support from participating CHCs regarding any mental illness and substance use problems in the last three months. 

Seven CHCs in the Greater Toronto Area with relatively significant proportions of individuals with mental illness and substance use problems in their catchment areas, are now participating:

  • Black Creek Community Health Centre
  • Rexdale Community Health Centre
  • Regent Park Community Health Centre
  • TAIBU Community Health Centre
  • LAMP Community Health Centre
  • Women’s Health in Women’s Hands Community Health Centre
  • Stonegate Community Health Centre

Each CHC will also have a “team of champions” to help them to implement the study as well as provide input and recommendations to the research team.

What is being done?

This project officially began in April 2014. Participating CHC staff and clients are now completing baseline surveys and interviews, and clients will complete surveys again at 6, 12, and 24 months. Surveys are available in 12 languages to allow further participation from culturally diverse clients. 

Four of the CHCs will be randomly selected to receive the anti-stigma intervention, while the remaining three will act as control sites and will not receive the intervention. Once the study is complete, the three control sites will receive the intervention. 

In year two, staff at the intervention sites will receive contact-based educational training over the course of four workshops. These sessions will incorporate results from a preliminary situational assessment conducted at each site. They will include presentations on prejudice and social intolerance, and the perspectives of vulnerable populations. Consumer-survivors will play an integral role by providing the ‘contact’ piece of the training. They will share their experiences with stigma, participate in panel discussions and facilitate small group work. 

In year three, arts-based recovery workshops will provide a forum for further contact-based education between staff and clients, which will take place over ten bi-weekly sessions. Ten clients are expected to participate with three staff per CHC. Staff and clients will explore the concept of recovery through facilitated discussions, providing the foundation for working together to develop recovery oriented art that speaks to stigma. The art work produced during these workshops will then be displayed at the CHC after the final workshop session. 

The project also includes an analysis of selected policies and procedures from each CHC, using a policy analysis tool developed specifically for this comprehensive model. It includes various analysis toolkits, including the World Health Organization’s Quality Rights Tool Kit Assessment tools and the Health Equity Impact Assessment Tool. The team of champions will also play a key role in helping to identify these policies and procedures. 

Finally, an evaluation component of the study will look at the process to determine how the intervention is being implemented and received, the strengths and weaknesses, and what activities occurred under what conditions. This evaluation is intended to clarify the context and to make sure the intervention is being adequately implemented. 

What are the expected outcomes of the research?

The team expects that the intervention sites will see a significant decrease in the level of stigmatizing and discriminatory attitudes towards clients with mental illness and substance use problems among primary health care providers and fewer experiences of stigma among these clients.

What are the limitations of the research?

Potential limitations include:

  • Non-response bias – when the selected or volunteered participants are more cooperative and communicative, and may also be more tolerant. 
  • Social desirability bias – when participants provide answers on the basis of what they assume the researchers would regard as favourable. 
  • Difficulties in measuring attitudes – studies focusing on measuring attitudes are rare so there is a lack of evidence to build upon. 

Is this research applicable in other contexts?

The team hopes that this research will create the evidence-base needed to support the widespread use of this intervention within primary health care as well as other sectors, such as housing. Furthermore, this model is currently being tested in Peru and Chile through the Office of Transformative Global Health at CAMH.

For more information about this research, please contact::
Akwatu Khenti, Director of Transformative Global Health, CAMH
(416) 535-8501 Ext. 36684
Akwatu [dot] Khenti [at] camh [dot] ca

Emily Lentinello, Project Coordinator, Transformative Global Health, CAMH
(416) 535-8501 Ext. 34323
Emily [dot] Lentinello [at] camh [dot] ca