Reducing stigma in primary health care settings - CAMH's Office of Transformative Global Health

By Tatyana Krimus

In brief

Ending StigmaThe stigma, or shame, associated with mental illness often stops people from seeking help for their mental health and/or substance use concerns, and is therefore a barrier to their recovery. This stigma is sometimes the result of the individual’s own shame about having a mental health concern or as a result of the negative perceptions of people they encounter when they seek mental health services.

The Office of Transformative Global Health (OTGH) at the Centre for Addiction and Mental Health designed and tested a stigma-reduction, pro-recovery intervention to reduce stigmatizing attitudes and behaviours among primary health care providers. OTGH joined with community health centres working with vulnerable populations in the Greater Toronto Area to address stigma. They worked closely with each CHC to identify, assess, and address stigmatizing attitudes, practices, and procedures.

In this Evidence in Action, we profile their stigma-reduction initiative. Evidence in Action profiles knowledge generation, exchange, and implementation activities across Ontario.

About the initiative

The stigma, or shame, associated with mental illness often stops people from seeking help for their mental health and/or substance use concerns, and is therefore a barrier to their recovery. This stigma is sometimes the result of the individual’s own shame about having a mental health concern or as a result of the negative perceptions of people they encounter when they seek mental health services. 

In 2010, the Office of Transformative Global Health (OTGH) at the Centre for Addiction and Mental Health (CAMH) received funding to design and pilot a stigma-reduction, pro-recovery intervention to reduce stigmatizing attitudes and behaviours among primary health care providers. 

OTGH joined with community health centres (CHCs) working with vulnerable populations in the Greater Toronto Area to address stigma. They worked closely with each CHC to identify, assess, and address stigmatizing attitudes, practices, and procedures.

Initially funded by the Development and Dissemination Fund at CAMH, the OTGH received funding from Opening Minds at the Mental Health Commission of Canada in 2012 to continue the initiative for an additional three years. 

Developing the Initiative

The first step of the initiative was to conduct a review of the evidence published on the topic of stigma among health care providers and stigma-reduction interventions in primary health care settings. This research confirmed that there is a lack of information on interventions that address stigma in primary care.

OTGH staff then reached out to a number of CHCs to determine their level of interest in participating in a stigma-reduction initiative. Three of them – Unison Health and Community Services, South Riverdale Community Health Centre and Central Toronto Community Health Centre – showed interest in being involved in research and developing an intervention in partnership with the OTGH. 

Focus groups and semi-structured interviews were used to explore stigma from the perspective of frontline staff and management in both clinical and community-based programs. Information was collected from health care providers on stigmatizing perspectives, willingness to work with people with mental illness, and attitudes towards recovery. They were also asked to suggest stigma-reduction interventions.

OTGH also organized a symposium to bring together CHC staff, CAMH stigma experts, and an expert advisory panel to discuss research findings and determine ways to address stigma at the organizational level. Finally, participants identified several components to make up a recovery-oriented, stigma-reduction intervention.  

The Intervention

A comprehensive intervention was developed to address the unique needs of each CHC. It is divided into six parts: 

  • Development of teams of leaders: A core team of local champions made up of staff and a patient community advisory group played a crucial supporting role. 
  • Contact-based education: Primary health care providers had opportunities to learn from individuals who had previously received mental health or addiction services who participated as co-facilitators in training.  
  • Raising awareness: Social media and other innovative approaches were used to bring attention to the persistence of stigma in primary health care.
  • Recovery-based arts: This component involved primary health care providers and consumer-survivors working together on creative projects to develop a common understanding of stigma, discrimination, and recovery. 
  • Analysis of internal policies and procedures: Using an anti-stigma/anti-discrimination lens, OTGH developed a tool that combines a number of validated instruments to analyze CHC policies and procedures.
  • Context-specific innovation: This flexible component was included so that each CHC could identify a specific activity that was tailored to its location and the populations it serves. 

The Results

Preliminary evaluation results show that CHC staff who participated in contact-based education training had an 8.5% reduction in stigmatizing attitudes towards people with mental health or substance use issues. 

These findings were attributed to the direct contact between health care providers and consumer-survivors. The group exercises and discussion fostered awareness of the role that stigma and discrimination play in the lives of those with mental health and substance use issues. 

Through this comprehensive intervention, OTGH addresses stigma and access to services, as well as promotes positive and safe environments for recovery. 

The next phase of this project will be a large-scale research study funded by the Canadian Institutes for Health Research. This randomized control study will test whether this intervention is changing how health care providers feel and behave towards people with mental illness or substance use issues. Read a summary of the study here. 

Lessons Learned

OTGH effectively partnered with CHCs to deliver a “systems punch” by identifying issues and crafting a tailored approach to combat stigma at an organizational level. 

The greatest challenge faced is resource and budget constraints. CHCs are busy with multiple competing priorities and are often under-staffed and under-funded, which makes it difficult for them to fully participate in all aspects of the project. For this reason, OTGH integrated this intervention into structures that are already in place within the CHCs to ensure that it can be sustained over the long term.

The stigma reduction initiative offers a low-cost, high-return approach at a time when the health sector is constantly being asked to do “more with less.” The project is cost effective because it does not require a lot of resources to implement, while having a significant positive impact on CHC staff and clients. 

Akwatu Khenti, Director of the OTGH, believes this integrated, comprehensive approach could significantly reduce overall stigmatizing attitudes. 

For more information, contact Sireesha Bobbili, Special Advisor / Project Coordinator, Office of Transformative Global Health, CAMH, at Sireesha [dot] Bobbili [at] camh [dot] ca.

Stay up to date on work that the Office of Transformative Global Health is doing on Twitter, @akwatukhenti.

For more information on the Stigma Reduction Initiative in Primary Health Care in Ontario: www.porticonetwork.ca/web/ontario-phc-antistigma.