Mass media interventions for reducing mental health-related stigma

The influencing factors of stigma towards people with mental illness among nursing students: a mixed-method systematic review

The stigma of nursing students towards people with mental illness (PMI) creates significant barriers to diagnosis, treatment, and recovery for those with PMI. It can also have a significant impact on the future career choices of nursing students in the field of psychiatry. Current research has found various influencing factors, including personal characteristics and educational influences. However, a comprehensive analysis that encompasses all aspects is lacking. The aim of the study was to conduct a convergent mixed-method systematic review to synthesize the influencing factors of the stigma of nursing students towards PMI according to Framework Integrating Normative Influences on Stigma (FINIS) at micro, meso, and macro levels. PubMed, Web of Science, Cochrane Library, EMBASE, CINAHL and PsycINFO were searched from 1990 to 31 December 2023. The reference lists of the included literature were further checked to identify potentially relevant articles. Two authors independently screened all titles, abstracts, and full-text articles and extracted data. Study quality was assessed by two authors using the Mixed Method Appraisal Tool (MMAT). A total of 4865 articles were initially retrieved, and 73 of these articles were included. The results suggested that the stigma towards PMI by nursing students was influenced by micro, meso and macro levels. At each FINIS level, the most frequent influencing factors are personal characteristics, the treatment system and media images. Numerous interconnected factors exert an influence on the stigma towards PMI among nursing students. Our research can be used to identify barriers and facilitators to nursing students' stigma towards PMI and to provide supporting information for interventions designed to reduce this stigma.

Ignored inequities: Critical analysis of the pre-launch development of British Columbia's "Stop Overdose" campaign

BACKGROUND

Substance use stigma has been positioned as a major driver of drug toxicity mortality. In response, governmental and public health organizations across Canada have invested significant resources into mass media campaigns that target stigma. Many of these campaigns feature images or stories about people who use drugs (PWUD). Although stigma and drug toxicity death disproportionately impact racially and economically marginalized PWUD, these campaigns often over-represent White, middle-class individuals. This effectively ignores intersecting roles of racism and classism in the experience of stigma and drug toxicity mortality.

METHODS

To investigate how this pattern of representation might occur, we examined the development process of the British Columbia (BC) Government's "Stop Overdose" anti-stigma campaign launched in 2018. We aimed to identify strategic goals, decisions, and underlying ideas that could help explain the campaign's eventual focus on White, middle-class PWUD. Through a Freedom of Information request we obtained 320 pages of documents from the BC Government outlining the real-time development, testing, and evaluation of the first wave of the campaign. We analyzed these documents using reflexive thematic analysis.

RESULTS

We identified that campaign developers had a marked focus on challenging stereotypes about PWUD and humanizing PWUD, while ensuring the campaign was relevant to BC residents. To achieve these goals, campaign developers ultimately avoided images of what they deemed the inaccurately "stereotypical" marginalized drug user. Instead, they featured PWUD in more privileged social positions. By attaching labels like "co-worker" to this imagery, developers felt mainstream BC residents could relate to and have more empathy for these PWUD compared to marginalized PWUD.

CONCLUSIONS

In effect, these strategies perpetuated the exclusion and dehumanization of marginalized PWUD facing disproportionate harms of the drug toxicity crisis. Since anti-stigma campaigns remain a common intervention, we highlight a need for strategic approaches informed by more critical perspectives on substance use stigma.

Assessing mental health literacy in Jordan: a factor analysis and Rasch analysis study

Background

Mental health literacy (MHL) research in Jordan is sparse and validated MHL measures are lacking. The present study validated a Jordanian version of the Mental Health Literacy Scale (MHLS) and examined Jordanian individuals' MHL.

Method

A Google Forms survey was designed, and the link was shared through various Jordanian social media platforms. Factor analysis and Rasch analysis were performed to validate the Jordanian version of the MHLS. Binary logistic regression was performed to assess variables associated with MHL.

Results

The Jordanian MHLS was administered to 974 participants (74.4% females; median age 27 years). The mean MHL score of the participants was 71.1% indicating average literacy levels. The factor analysis indicated that 27 items distributed across four factors had the best model fit. The Rasch analysis confirmed item separation reliability and person reliability. The regression showed a correlation between educational attainment, income, marital status and MHL level. These findings emphasize the role of educational attainment in MHL, pointing to the necessity of integrating mental health education into formal curricula to enhance MHL across all societal levels. Stigma and limited-service availability act as barriers to mental health service and access, which compound the challenge of improving MHL. Targeted educational interventions and policy reforms may help improve MHL, thereby contributing to improving mental health outcomes in Jordan and potentially other similar settings.

Experiences of stigma, discrimination and violence and their impact on the mental health of health care workers during the COVID-19 pandemic

Health care workers have been exposed to COVID-19 more than people in other professions, which may have led to stigmatization, discrimination, and violence toward them, possibly impacting their mental health. We investigated (1) factors associated with stigma, discrimination, and violence, (2) the association of stigma, discrimination, and violence with mental health, (3) everyday experiences of stigmatization, discrimination, and violence. We chose a combination of a quantitative approach and qualitative content analysis to analyze data collected at three time points: in 2020, 2021 and 2022. A higher age was associated with lower odds of experiencing stigma, discrimination, and violence, whereas female gender was related to more negative experiences. The intensity of exposure to COVID-19 was associated with greater experience with stigmatization, discrimination, and violence across all three years (for example in 2022: odds ratio, 95% confidence interval: 1.74, 1.18-2.55 for mild exposure; 2.82, 1.95-4.09 for moderate exposure; and 5.74, 3.55-9.26 for severe exposure, when compared to no exposure). Stigma, discrimination, and violence were most strongly associated with psychological distress in 2020 (odds ratio = 2.97, 95% confidence interval 2.27-3.88) and with depressive symptoms in 2021 (odds ratio = 2.78, 95% confidence interval 2.12-3.64). Attention should be given to the destigmatization of contagious diseases and the prevention of discrimination, violence, and mental health problems, both within workplaces and among the public.

The moderating role of stigma in the relationship between depression and resilience: results of a cross-sectional study in university students

Background/objective

Depression is a growing concern in university students and resilience has shown to play a protective role. The impact of stigma is still under-explored, with reference to its moderating role between depression and resilience. The present study investigate such a relationship among Italian university students.

Methods

A cross-sectional design was applied in a simple of 1,912 students to examine the interrelationships between depression (Patient Health Questionnaire-9), resilience (Nicholson McBride Resilience questionnaire), and stigma (Stigma-9). Correlation, predictor, and moderation analyses were applied in RStudio.

Results

A negative correlation was found between depressive symptoms and resilience (r = -0.455, p < 0.001). A positive correlation was found between depressive symptoms and stigma (r = 0.207, p < 0.001). Lower levels of resilience and higher levels of stigma were significant predictors of depressive symptoms [F(df, n) = 190.8(3, 1884), p < 0.001, R2 = 0.236]. The moderation analysis showed a weakening of resilience protective effect against depression as stigma levels increase [F(df,n) = 186.7(3,1908), p < 0.001, R2 = 0.226].

Conclusion

Stigma influences the relationship between depression and resilience. Anti-stigma interventions and programs empowering resilience, should be implemented in university settings to protect students from depression.

How discrimination experiences relate to racial/ethnic identity and mental health across first- and second-generation Vietnamese American adolescents

OBJECTIVES

Racial/ethnic discrimination has been linked to behavioral and emotional problems in youth from marginalized groups. However, the psychological experience associated with discrimination may differ between immigrant and nonimmigrant youth. Race-based discrimination may impact an adolescent's view of their own group (private regard) and/or their sense of how others view their group (public regard). Owing to differences in racialization, immigrant adolescents may be affected differently by experiences of discrimination than their U.S.-born peers. The present study examined whether nativity moderated the paths from racial/ethnic discrimination to private and public regard to mental health problems among Vietnamese American youth.

METHOD

Surveys were completed by 718 Vietnamese American 10th and 11th graders (Mage = 15.54 years, 61.4% female, 38.6% male). In this sample, 21.2% were first-generation (i.e., born outside of the United States) and 78.8% were second-generation (i.e., born in the United States with at least one parent born outside of the United States).

RESULTS

Multigroup path analysis tested the direct and indirect effects of racial/ethnic discrimination on behavioral and emotional problems via private and public regard and whether associations differed for first- versus second-generation youth. Racial/ethnic discrimination was associated with lower public regard, but not private regard, for both first- and second-generation Vietnamese American youth. Public regard was negatively associated with behavioral and emotional problems only among second-generation youth. No indirect effects were significant.

CONCLUSIONS

Findings suggest differences in racialized experiences, as well as opportunities to support second-generation Vietnamese American and other marginalized youth from immigrant families from the mental health impacts of discrimination. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

A study on the representation of mental disorders in Turkish newspapers

BACKGROUND

Newspapers that address mental disorders affect health care positively or negatively and can affect the public's perspective with the way they explain mental disorders.

AIMS

To examine the representation of news about mental disorders published in Turkish newspapers.

METHODS

Using the document analysis method, 230 news about mental disorders published in the six most read newspapers in 2022 were examined.

RESULTS

It has been concluded that the descriptive characteristics of individuals with mental disorders are often stated, schizophrenia and psychotic disorders are mentioned most, mental disorders are associated with delinquency and violent behaviour, these people are mostly represented by being detained as a result of the events, and negative concepts are frequently used in newspaper reports. Five sub-themes were determined under the main theme of "Negative Concepts": "Exaggerated Discourses", "Stigmatizing Discourses", "Discourses Targeting Mental Health", "Discourses That May Cause Negative Emotions", "Discourses Containing Misdescription".

CONCLUSIONS

Newspaper items about mental disorders are represented as stigmatizing and misleading by using negative concepts. The sensitivity of media workers, the development of mental health policies and cooperation with mental health workers contribute to the recovery process of individuals with mental disorders.

The Effectiveness of a Cell Phone eHealth App in Changing Knowledge, Stigmatizing Attitudes, and Intention to Seek Help Associated With Obsessive-Compulsive Disorder: Pilot Questionnaire Study

BACKGROUND

Obsessive-compulsive disorder (OCD) is a disabling disorder associated with high interference in people's lives. However, patients with OCD either do not seek help or delay seeking help. Research suggests that this could be explained by poor mental health literacy about the disorder and the associated stigma.

OBJECTIVE

This study aims to evaluate the feasibility, acceptability, and preliminary effectiveness of a mental health mobile app, esTOCma, developed to improve knowledge about OCD and its treatment, increase help-seeking intention, and reduce stigmatizing attitudes and social distance associated with OCD.

METHODS

We used preintervention, postintervention, and 3-month follow-up assessments in this single-arm pilot intervention. Overall, 90 participants were recruited from the community using the snowball sampling method. We used esTOCma to defeat the "stigma monster" over the course of 10 missions. The participants completed the sociodemographic information and Obsessive-Compulsive Inventory-Revised at preassessment and an acceptability questionnaire at postassessment. All other measures were completed at the preassessment, postassessment, and 3-month follow-up (ie, the Spanish Mental Illness Stigma Attribution Questionnaire-27, the General Help-Seeking Questionnaire, the Social Distance Scale, and the Mental Health Literacy Questionnaire).

RESULTS

Of the 90 participants from the community that were assessed for eligibility, 86% (n=78) were allocated to intervention. Of these 78 participants, 79% (n=62) completed the game and answered the postintervention assessment (completer group). Overall, 69% (43/62) of the participants also completed the 3-month follow-up assessment. The participants completing the study were older (P=.003) and had a higher baseline knowledge of OCD (P=.05). The participants took an average of 13.64 (SD 10.50) days to complete the intervention, including the pre- and postassessments. The participants spent an average of 4.56 (SD 3.33) days completing the 10 missions included in the app. Each mission took a mean of between 2 (SD 3.01) and 9.35 (SD 3.06) minutes. The app was rated as useful or very useful by the vast majority of participants 90% (56/62). Moreover, 90% (56/62) of the participants reported that they had learned or learned a lot, and 98% (61/62) of the participants reported that they would recommend the app to a friend. Repeated measures ANOVA (43/62, 69%) showed that after the intervention participants showed an increased knowledge of mental health and intention to seek help as well as fewer stigmatizing attitudes and less social distance.

CONCLUSIONS

Preliminary data show that esTOCma is a feasible and acceptable app, and after completing its 10 missions, there is an increase in the understanding of OCD and help-seeking intention along with a decrease in the social stigma and social distance associated with OCD that lasts for at least 3 months. The results support the potential of technology-based interventions to increase the intention to seek help and reduce the stigma associated with OCD. A larger, community-controlled study is also recommended.

A video-based intervention to overcome pregnancy smoking stigma among healthcare students: a randomised controlled trial

OBJECTIVES

This study tests a video intervention to reduce pregnancy smoking stigma among French healthcare students.

DESIGN

The participants were randomly selected to watch online either an experimental video (presenting educational content regarding stigma and contact with pregnant smokers) or a control video (presenting standard educational content about the risks of smoking). The students completed scales assessing stigma, intention to address smoking cessation and self-efficacy to do so, before the intervention (T0, n = 252), one week after the intervention (T1, n = 187), and one month after the intervention (T2, n = 131).

RESULTS

Compared to the medical students, especially men, the midwifery students reported lower derogative cognitions (η2p = .18), negative behaviours (η2p = .07) and personal distress (η2p = .06). However, the midwifery students also reported lower levels of intention to address smoking (η2p = .02) than the medical students. The experimental video decreased derogative cognitions to a greater extent than the control video (η2p = .23) in both the short and medium term. This study is the first intervention designed to reduce the stigmatisation of pregnant smokers by healthcare students. We recommend that the issue of stigma should receive more attention in the medical curriculum.

Effectiveness of Community-Based Programs on Aggressive Behavior Among Children and Adolescents: A Systematic Review and Meta-Analysis

Adolescent aggressive behavior has increasingly become a central issue affecting the safety of both school campuses and the broader society. Despite the existence of numerous community interventions targeting this issue, there has been a paucity of efforts to consolidate the findings on the effectiveness of community-based programs in preventing aggressive behavior. This meta-analysis sought to address this gap by reviewing and assessing the impact of community-based initiatives on reducing adolescent aggression. A thorough search was carried out on 12 electronic databases: EBSCO, ERIC, PubMed, PsycINFO, MEDLINE, EMBASE, Scopus, Web of Science, ProQuest Dissertations and Theses, the China National Knowledge, Wanfang Databases, and China Science and Technology Journal Database. Sixteen studies were finalized, and meta-analyses were performed using a random effect model on RevMan v5.4 software developed by Cochrane. The analysis encompassed 16 published studies, involving a total of 2,585 participants. The key components of existing programs for aggression reduction included providing behavioral skills and training for adolescents, employing a problem-solving approach to address behavioral issues, offering psychological treatment, and emphasizing community supervision. The results indicate a significant positive effect of community-based interventions on aggression reduction (standardized mean difference = -0.26, 95% confidence intervals [-0.39, -0.13], Z = 3.84, p < .001). The subgroup analyses revealed that the intervention's effectiveness was moderated by the duration of the intervention, its theoretical foundation, and the sample size. This study furnishes empirical evidence supporting the enhancement of policies and practices to foster community engagement in mitigating aggressive behavior.

Effects of media campaign videos on stigma and attitudes towards treatment seeking for alcohol use disorder: a randomized controlled study

BACKGROUND

Alcohol Use Disorder (AUD) is one of the most stigmatized diagnosis, and stigma imposes a major barrier to treatment seeking. There is a need to develop interventions that can reduce stigma and increase treatment seeking. Little is known about the effects of video materials. The aim of this study was to investigate effects of different videos. The primary outcome was public stigma, and secondary outcomes were: self-stigma, and motivation to change own alcohol use; talking to someone else about their alcohol use; seeking information about AUD treatment or seeking AUD treatment.

METHODS

This is a three-armed double blind randomized controlled study. The study included 655 Danish adults. Data was collected at a study webpage, and the survey could be completed anywhere with Internet access. After informed consent and completing baseline measures, participants were randomized, 1:1:1 ratio, to a video (video 1 n = 228; video 2 n = 198; video 3 n = 229). Video 1 and 2 have been used in a national mass media campaign and video 3 was recorded for use in the present study. Immediately after exposure, follow-up measures were completed. Outcomes were analyzed with mixed effects linear regression.

RESULTS

In total n = 616 completed follow-up (video 1 n = 215; video 2 n = 192; video 3 n = 209). Randomization to video 1 and 3 decreased public stigma measured with "Difference, Disdain & Blame Scales", while video 2 increased stigma. Video 2 compared to 1: 2.262 (95% CI 1.155; 3.369) p < 0.001. Video 3 compared to 1: -0.082 (95% CI -1.170; 1.006) p = 0.882. Video 3 compared to 2: -2.344 (95% CI -3.455; -1.233) p = 0.882. All videos reduced motivation to change own alcohol use. Participants with hazardous alcohol use, were more sensitive to the different videos, compared to low-risk alcohol use. Video 2 decreased motivation to seek information about treatment. No effects were seen on motivation to seek treatment, motivation to talk to someone else or self-stigma.

CONCLUSIONS

Videos can have an immediate effect on level of public stigma. Other types of interventions are needed to increase motivation and reduce self-stigma. To avoid adverse effects in future interventions, the use of theoretical frameworks and stakeholder involvement is emphasized.

The Influence of Media on the Stigma of Suicide when a Postsecondary Student Dies by Suicide

This study investigated whether media articles from a postsecondary institution could influence students' stigma toward suicide after a student dies by suicide. Undergraduate participants (N = 425) read a fictitious scenario about a student suicide and were randomly assigned to a control article (no mention of the suicide) or one of three intervention articles that acknowledged the suicide and included a discussion with a psychologist, a friend of the decedent, or a suicide survivor. The stigma toward suicide survivors, particularly stereotypes, was significantly less after the three intervention articles compared to the control. No differences were found between the intervention articles or regarding the stigma toward suicide decedents. Reduced stigma toward survivors indicates that acknowledging a suicide, when possible, should be considered.

An exploratory study on the 10-year dynamic changes of mental health policy development and media stigma reporting in China (2011-2020)

BACKGROUND

China has introduced a large number of national mental health policies over the past decade. However, few studies have touched on what changes the policies brought to the media.

AIMS

This study aimed to investigate the relationship between stigma reports, classifications of mental disorders (SMI: severe mental illness vs. CMD: common mental disorders) and sources of information (mental health professionals vs. non-mental health professionals) from 2011 to 2020 in China Daily, an established official media of China.

METHOD

This study consists of policy review and media review. The policy review reviewed the media management content in Chinese national plans, policies, and laws on mental health from 2011 to 2020. China Daily news articles reporting mental illness-related topics were included in this study as the media material. After a two-step review, the eligible news articles were coded with a structured codebook. The proportion and frequency of stigma depiction of mental disorders, classifications of mental disorders and source of information were counted by year. Chi-test was undertaken to determine the relationship between stigma reports and different classifications of mental disorders and sources of information. An exploratory analysis was conducted to explore the changes in depiction around time points of policy publications.

RESULTS

The number of anti-stigmatizing articles increased significantly from 2011 to 2020. There is a statistical difference in the proportion of stigmatizing codes between articles featuring SMI and CMD (χ2 = 44.56, p < .001) and different sources of information (χ2 = 78.49, p < .001). And the statistical difference remained over the decade.

CONCLUSION

The results of the research indicate that the media may have alleviated the problem of stigma. But the subtle stigmatization still exists, which needs joint efforts of the government and media.

Pregnant in a Pandemic: Mental Wellbeing and Associated Healthy Behaviors Among Pregnant People in California During COVID-19

INTRODUCTION

Pregnancy is a time of increased vulnerability to mental health disorders. Additionally, the COVID-19 pandemic has increased the incidence of depression and anxiety. Thus, we aimed to assess mental health and associated healthy behaviors of pregnant people in California during the pandemic in order to contextualize prenatal well-being during the first pandemic of the twenty-first century.

METHODS

We conducted an online cross-sectional study of 433 pregnant people from June 6 through July 29, 2020. We explored 3 hypotheses: (1) mental health would be worse during the pandemic than in general pregnant samples to date; (2) first-time pregnant people would have worse mental health; and (3) healthy behaviors would be positively related to mental health.

RESULTS

Many of our participants (22%) reported clinically significant depressive symptoms and 31% reported clinically significant anxiety symptoms. Multiparous pregnant people were more likely to express worries about their own health and wellbeing and the process of childbirth than were primiparous pregnant people. Additionally, as pregnancy advanced, sleep and nutrition worsened, while physical activity increased. Lastly, anxious-depressive symptomology was significantly predictive of participant sleep behaviors, nutrition, and physical activity during the past week.

DISCUSSION

Pregnant people had worse mental health during the pandemic, and this was associated with worse health-promoting behaviors. Given that the COVID-19 pandemic and associated risks are likely to persist due to low vaccination rates and the emergence of variants with high infection rates, care that promotes mental and physical well-being for the pregnant population should be a public health priority.

Working alliance in low-intensity internet-based cognitive behavioral therapy for depression in primary care in Spain: A qualitative study

Introduction

Psychotherapies delivered via the Internet have been promoted as an alternative for improving access to psychological treatments. A conceptual working alliance model of blended (i.e., traditional face-to-face consultation combined with Internet-delivered psychotherapy) cognitive-behavioral therapy (b-CBT) for depression has been developed in the UK. However, little is known about how this important therapeutic process, namely the working alliance (WA), is developed and maintained in Internet-delivered cognitive-behavioral therapy without face-to-face consultation (i-CBT). The aim of this study was to evaluate the validity of the WA model of b-CBT in Spanish patients with depression receiving i-CBT.

Methods

Forty-one patients suffering from mild-moderate depression were interviewed to assess their experiences of an i-CBT program. Interviews were conducted with participants who received a self-guided application (n = 9), and low-intensity support (n = 10). Three group interviews were also conducted with patients who either did not start the program (n = 8) or did not complete it (n = 6), and with patients who did complete it (n = 8).

Results

Qualitative thematic content analysis was performed using the constant comparative method, which revealed four main themes: “bond,” “goals,” “task,” and “usability heuristics,” all consistent with the existing literature. However, a new subcategory emerged, called “anonymity,” which may highlight the social stigma that mental illness still has in the Spanish context.

Conclusion

Results suggest that the development and maintenance of the WA through i-CBT could offer a better experience of the therapeutic process and improve the clinical impact.

Clinical Trial Registration

Clinicaltrials.gov, identifier: NCT01611818.

Stigma as a barrier to early intervention among youth seeking mental health services in Ontario, Canada: a qualitative study

BACKGROUND

Stigma associated with mental health challenges is a major barrier to service seeking among youth. Understanding how stigma impacts service-seeking decisions from the perspectives of youth remains underexplored. Such research is necessary to inform effective stigma reduction.

OBJECTIVE

This study aims to understand how stigma influences service seeking among youth with mental health challenges.

METHODS

Qualitative inquiry was taken using youth engagement, underpinned by pragmatism. Data were collected via 4 virtual focus groups with 22 purposively selected youth participants with lived experience of mental health challenges in Ontario, Canada. Focus group guides were developed collaboratively among research team members, including youth co-researchers. Data were analyzed inductively using reflexive thematic analysis.

RESULTS

Three main themes were constructed from the data: point of entry into the system, being biomedicalized or trivialized, and paving the way for non-stigmatizing services. Initial contact with the mental healthcare system was seen to be affected by stigma, causing participants to delay contact or be refused services if they do not fit with an expected profile. Participants described a constant negotiation between feeling 'sick enough' and 'not sick enough' to receive services. Once participants accessed services, they perceived the biomedicalization or trivialization of their challenges to be driven by stigma. Lastly, participants reflected on changes needed to reduce stigma's effects on seeking and obtaining services.

CONCLUSION

A constant negotiation between being 'sick enough' or 'not sick enough' is a key component of stigma from the perspectives of youth. This tension influences youth decisions about whether to seek services, but also service provider decisions about whether to offer services. Building awareness around the invisibility of mental health challenges and the continuum of wellness to illness may help to break down stigma's impact as a barrier to service seeking. Early intervention models of care that propose services across the spectrum of challenges may prevent the sense of stigma that deters youth from accessing and continuing to access services.

Using Relational Frame Theory to Examine Racial Prejudice: A Tool for Educators and an Appeal for Future Research

Canadian colleges and universities have begun to acknowledge systemic and institutionalized racism by developing equity statements and policies in support of diverse and accessible learning environments. To encourage these equitable statements and policies as actionable, analysis of racial bias and methods for reducing its occurrence are warranted. In this article, literature on relational frame theory in the context of racial prejudice is reviewed, including treatment approaches shown to be less effective and those that appear promising. The integration of a functional contextual approach into pedagogy is considered with an aim to better understand the origins of racial prejudice. Finally, recommendations on the examination of personal and sociocultural bias among educators and their students are provided.

Indirect social contact interventions to reduce mental health-related stigma in low- and middle-income countries: systematic review

AIMS

Mental health-related stigma and discrimination are a complex and widespread issue with negative effects on numerous aspects of life of people with lived experience of mental health conditions. Research shows that social contact is the best evidence-based intervention to reduce stigma. Within the context of a rapid development of remote technology, and COVID-19-related restrictions for face-to-face contact, the aim of this paper is to categorise, compare and define indirect social contact (ISC) interventions to reduce stigma and discrimination in mental health in low- and middle-income countries (LMICs).

METHODS

MEDLINE, Global Health, EMBASE, PsychINFO, Cochrane Central Register of Control Trials (CENTRAL), Cumulative Index to Nursing and Allied Health Literature (CINAHL) were searched using a strategy including terms related to 'stigma and discrimination', 'intervention', 'indirect social contact', 'mental health' and 'low- and middle-income countries'. Relevant information on ISC interventions was extracted from the included articles, and a quality assessment was conducted. Emerging themes were coded using a thematic synthesis method, and a narrative synthesis was undertaken to present the results.

RESULTS

Nine studies were included in the review overall. One study was ineffective; this was not considered for the categorisation of interventions, and it was considered separately for the comparison of interventions. Of the eight effective studies included in synthesis, interventions were categorised by content, combination of stigma-reducing strategies, medium of delivery, delivery agents, target condition and population, as well as by active or passive interaction and follow-up. Most of the interventions used education and ISC. Recovery and personal experience were important content components as all studies included either one or both. Cultural adaptation and local relevance were also important considerations.

CONCLUSIONS

ISC interventions were effective in overall terms for both the general public and healthcare providers, including medical students. A new definition of ISC interventions in LMICs is proposed. More research and better reporting of intervention details are needed to explore the effectiveness of ISC strategies in LMICs, especially in regions where little relevant research has been conducted.

Why So Serious? An Attempt to Mitigate the Short-Term Harmful Effects of the Film Joker on Prejudice toward People with Mental Illness

The media perpetuates many harmful stereotypes about people with mental illness. In two studies, we demonstrate the impact of negative media portrayals of mental illness on prejudice and attempt to mitigate these negative effects. Specifically, in Study 1, participants watched the movie Joker, a recent film which associates mental illness with violent behavior, or a control film (Terminator). Participants completed the Prejudice towards People with Mental Illness (PPMI) scale before and after viewing their respective films. The PPMI consists of four dimensions: fear/avoidance (i.e., wanting to avoid people with mental illness), malevolence (i.e., viewing people with mental illness as inferior), authoritarianism (i.e., preference for control over people with mental illness), and unpredictability (i.e., the behavior of people with mental illness is unreliable). We hypothesized that participants who watched the film Joker would display an increase in their fear/avoidance of people with mental illness and their support for authoritarian approaches to their treatment. Consistent with these hypotheses, participants who viewed Joker displayed a significant increase in the fear/avoidance and authoritarian subscales of the PPMI, relative to participants that watched Terminator. In Study 2, in an attempt to mitigate the impact of Joker on prejudice towards people with mental illness, directly after the film we displayed educational and counter-stereotypical statements on-screen that challenged the view that people with mental illness are violent. A control group viewed Joker without these statements. Identical to Study 1, all participants completed the PPMI scale before and after viewing the film. We hypothesized that participants who viewed Joker with the statements would display lower prejudice relative to the control condition. Unfortunately, participants in the experimental and control conditions displayed a comparable increase in prejudice. Together, these studies confirm the negative effect of media portrayals of mental illness (as depicted in Joker) and demonstrate that these effects are not easily mitigated.

COVID-19 vaccine acceptance and perceived stigma in patients with depression: a network perspective

The association between coronavirus disease (COVID-19) vaccine acceptance and perceived stigma of having a mental illness is not clear. This study examined the association between COVID-19 vaccine acceptance and perceived stigma among patients with recurrent depressive disorder (depression hereafter) using network analysis. Participants were 1149 depressed patients (842 men, 307 women) who completed survey measures of perceived stigma and COVID-19 vaccine attitudes. T-tests, chi-square tests, and Kruskal-Wallis tests were used to compare differences in demographic and clinical characteristics between depressed patients who indented to accepted vaccines and those who were hesitant. Hierarchical multiple regression analyses assessed the unique association between COVID-19 vaccine acceptance and perceived stigma, independent of depression severity. Network analysis examined item-level relations between COVID-19 vaccine acceptance and perceived stigma after controlling for depressive symptoms. Altogether, 617 depressed patients (53.7%, 95 confidence intervals (CI) %: 50.82-56.58%) reported they would accept future COVID-19 vaccination. Hierarchical multiple regression analyses indicated higher perceived stigma scores predicted lower levels of COVID-19 vaccination acceptance (β = -0.125, P < 0.001), even after controlling for depression severity. In the network model of COVID-19 vaccination acceptance and perceived stigma nodes, "Feel others avoid me because of my illness", "Feel useless", and "Feel less competent than I did before" were the most influential symptoms. Furthermore, "COVID-19 vaccination acceptance" had the strongest connections with illness stigma items reflecting social rejection or social isolation concerns ("Employers/co-workers have discriminated", "Treated with less respect than usual", "Sense of being unequal in my relationships with others"). Given that a substantial proportion of depressed patients reported hesitancy with accepting COVID-19 vaccines and experiences of mental illness stigma related to social rejection and social isolation, providers working with this group should provide interventions to reduce stigma concerns toward addressing reluctance in receiving COVID-19 vaccines.

Investigation of the relationship between incidence of mental disorders and economic growth among the Visegrad countries

Prevention and care for mental disorders represent an important public health task in achieving global development goals. Proper access to adequate healthcare and social services is an important step related to care for mental disorders, which is presumably strongly related to economic growth. The main aim of the study was to investigate the relationship between the economic growth and the incidence of mental disorders in the V4 countries. An ecological correlation study was conducted regarding the four Visegrad countries. Indicators were derived from the World Health Organization (WHO) 'Health for All' (HFA) online database and Penn World Table version 10. The incidence of mental disorders increased in the V4 countries throughout the years between 2000-2018 except in Hungary, where a decreasing trend was observed. The prevalence of mental disorders increased in all countries as well, but it stagnated in Hungary. At the same time standardized death rate due to mental disorders increased in all Visegrad countries. According to the Hungarian data, while the prevalence of the disease did not change remarkably, the incidence decreased and the mortality increased as well as the prescription of drugs used in the treatment of mental disorders. This could indicate a serious hidden morbidity.

Major Depressive Disorder in Iran: Epidemiology, Health Care Provision, Utilization, and Challenges

One in eight adults in Iran is estimated to have major depressive disorder (MDD) - a leading cause of disability in the country. Many remain undiagnosed, and some receive only partial treatment. An estimated 60% of those with MDD were reported to have received no treatment during the past year. In this paper, we have critically reviewed the current health-care structure in the country along with prevailing patterns of health-care service utilization. We have addressed the role of psychiatrists, general practitioners (GPs), psychologists, and other health-care personnel in the treatment and care of patients with MDD, with an emphasis on the quality of service provision. In addition, the strengths and weaknesses of primary healthcare (PHC), the health insurance system, and inpatient care have been discussed. We have paid attention to the contextual issues such as mental health literacy, stigma, and healthcare inequity where relevant. Finally, practical recommendations have been provided to improve the quality of care for patients with MDD in Iran.

Peer-to-peer contact, social support and self-stigma among people with severe mental illness in Hong Kong

BACKGROUND

Self-stigma exerts a range of adversities for persons with severe mental illness (SMI), however, little is known about the association between peer contact, social support and self-stigma.

AIMS

This study aimed to explore the mediating role of social support on the relationship between peer contact and self-stigma among persons with SMI in Hong Kong.

METHODS

A total of 159 persons with SMI (schizophrenia and mood disorder) in community service centres participated in the study through completing a survey on self-stigma, social functioning, social support, perception of peer contact and mass media. Logistic regression was utilised to explore the influencing factors of self-stigma among the participants.

RESULTS

The results showed that 81.1% of participants reported moderate to severe levels of self-stigma. Self-stigma was significantly associated with diverse factors (e.g. social functioning). Importantly, positive peer contact was significantly associated with lower self-stigma of persons with SMI. Social support acted as a mediator between peer contact and self-stigma.

CONCLUSION

The results of this study suggest that contact-based interventions, such as enhancing positive peer-to-peer contact, should be conducted for reducing self-stigma among persons with SMI.

Effectiveness of arts interventions to reduce mental-health-related stigma among youth: a systematic review and meta-analysis

BACKGROUND

Educational interventions engage youth using visual, literary and performing arts to combat stigma associated with mental health problems. However, it remains unknown whether arts interventions are effective in reducing mental-health-related stigma among youth and if so, then which specific art forms, duration and stigma-related components in content are successful.

METHODS

We searched 13 databases, including PubMed, Medline, Global Health, EMBASE, ADOLEC, Social Policy and Practice, Database of Promoting Health Effectiveness Reviews (DoPHER), Trials Register of Promoting Health Interventions (TRoPHI), EPPI-Centre database of health promotion research (Bibliomap), Web of Science, PsycINFO, Cochrane and Scopus for studies involving arts interventions aimed at reducing any or all components of mental-health-related stigma among youth (10-24-year-olds). Risk of bias was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. Data were extracted into tables and analysed using RevMan 5.3.5.

RESULTS

Fifty-seven studies met our inclusion criteria (n = 41,621). Interventions using multiple art forms are effective in improving behaviour towards people with mental health problems to a small effect (effect size = 0.28, 95%CI 0.08-0.48; p = 0.007) No studies reported negative outcomes or unintended harms. Among studies using specific art forms, we observed high heterogeneity among intervention studies using theatre, multiple art forms, film and role play. Data in this review are inconclusive about the use of single versus multiple sessions and whether including all stigma components of knowledge, attitude and behaviour as intervention content are more effective relative to studies focused on these stigma components, individually. Common challenges faced by school-based arts interventions included lack of buy-in from school administrators and low engagement. No studies were reported from low- and middle-income countries.

CONCLUSION

Arts interventions are effective in reducing mental-health-related stigma to a small effect. Interventions that employ multiple art forms together compared to studies employing film, theatre or role play are likely more effective in reducing mental-health-related stigma.

Key Barriers to the Provision and Utilization of Mental Health Services in Low-and Middle-Income Countries: A Scope Study

Inadequate attention has been given to the provision of mental health (MH) services especially in low-and middle-income countries (LMICs). This study was aimed to identify key barriers to provide and utilize MH services in LMICs. A comprehensive search on7 important online databases was conducted for key barriers to the provision and utilization MH services in LMICs from Jan 2000 to Nov 2019. Five-step Arksey and O'Malley guideline was used for scope study. The extracted data were synthesized using a qualitative content analysis and thematic network. Three main themes identified as barriers to the provision of MH services in LMICs, namely resource and administrative barriers, information and knowledge barriers, as well as policy and legislation barriers. Also attitudinal barriers, structural barriers, knowledge barriers, and treatment-related barriers were four main themes emerged regarding the challenges of utilization of MH services. Equitable access to MH services in LMICs is influenced by many barriers in both provision and utilization sides. In order to alleviate these problems, health systems could adopt some strategies including integration of MH into the general health policy, improvement of public MH awareness, developing anti-stigma programs, reallocation of health resources toward high-priority MH needs, developing community-based insurance, as well as integration of MH services into all levels of health-care systems. The success of intervention strategies depends on the weight of these barriers in different socio-economic contexts.

Behavioural interventions delivered through interactive social media for health behaviour change, health outcomes, and health equity in the adult population

BACKGROUND

Social networking platforms offer a wide reach for public health interventions allowing communication with broad audiences using tools that are generally free and straightforward to use and may be combined with other components, such as public health policies. We define interactive social media as activities, practices, or behaviours among communities of people who have gathered online to interactively share information, knowledge, and opinions.

OBJECTIVES

We aimed to assess the effectiveness of interactive social media interventions, in which adults are able to communicate directly with each other, on changing health behaviours, body functions, psychological health, well-being, and adverse effects. Our secondary objective was to assess the effects of these interventions on the health of populations who experience health inequity as defined by PROGRESS-Plus. We assessed whether there is evidence about PROGRESS-Plus populations being included in studies and whether results are analysed across any of these characteristics.

SEARCH METHODS

We searched CENTRAL, CINAHL, Embase, MEDLINE (including trial registries) and PsycINFO. We used Google, Web of Science, and relevant web sites to identify additional studies and searched reference lists of included studies. We searched for published and unpublished studies from 2001 until June 1, 2020. We did not limit results by language.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), controlled before-and-after (CBAs) and interrupted time series studies (ITSs). We included studies in which the intervention website, app, or social media platform described a goal of changing a health behaviour, or included a behaviour change technique. The social media intervention had to be delivered to adults via a commonly-used social media platform or one that mimicked a commonly-used platform. We included studies comparing an interactive social media intervention alone or as a component of a multi-component intervention with either a non-interactive social media control or an active but less-interactive social media comparator (e.g. a moderated versus an unmoderated discussion group). Our main outcomes were health behaviours (e.g. physical activity), body function outcomes (e.g. blood glucose), psychological health outcomes (e.g. depression), well-being, and adverse events. Our secondary outcomes were process outcomes important for behaviour change and included knowledge, attitudes, intention and motivation, perceived susceptibility, self-efficacy, and social support.

DATA COLLECTION AND ANALYSIS

We used a pre-tested data extraction form and collected data independently, in duplicate. Because we aimed to assess broad outcomes, we extracted only one outcome per main and secondary outcome categories prioritised by those that were the primary outcome as reported by the study authors, used in a sample size calculation, and patient-important.

MAIN RESULTS

We included 88 studies (871,378 participants), of which 84 were RCTs, three were CBAs and one was an ITS. The majority of the studies were conducted in the USA (54%). In total, 86% were conducted in high-income countries and the remaining 14% in upper middle-income countries. The most commonly used social media platform was Facebook (39%) with few studies utilising other platforms such as WeChat, Twitter, WhatsApp, and Google Hangouts. Many studies (48%) used web-based communities or apps that mimic functions of these well-known social media platforms. We compared studies assessing interactive social media interventions with non-interactive social media interventions, which included paper-based or in-person interventions or no intervention. We only reported the RCT results in our 'Summary of findings' table. We found a range of effects on health behaviours, such as breastfeeding, condom use, diet quality, medication adherence, medical screening and testing, physical activity, tobacco use, and vaccination. For example, these interventions may increase physical activity and medical screening tests but there was little to no effect for other health behaviours, such as improved diet or reduced tobacco use (20,139 participants in 54 RCTs). For body function outcomes, interactive social media interventions may result in small but important positive effects, such as a small but important positive effect on weight loss and a small but important reduction in resting heart rate (4521 participants in 30 RCTs). Interactive social media may improve overall well-being (standardised mean difference (SMD) 0.46, 95% confidence interval (CI) 0.14 to 0.79, moderate effect, low-certainty evidence) demonstrated by an increase of 3.77 points on a general well-being scale (from 1.15 to 6.48 points higher) where scores range from 14 to 70 (3792 participants in 16 studies). We found no difference in effect on psychological outcomes (depression and distress) representing a difference of 0.1 points on a standard scale in which scores range from 0 to 63 points (SMD -0.01, 95% CI -0.14 to 0.12, low-certainty evidence, 2070 participants in 12 RCTs). We also compared studies assessing interactive social media interventions with those with an active but less interactive social media control (11 studies). Four RCTs (1523 participants) that reported on physical activity found an improvement demonstrated by an increase of 28 minutes of moderate-to-vigorous physical activity per week (from 10 to 47 minutes more, SMD 0.35, 95% CI 0.12 to 0.59, small effect, very low-certainty evidence). Two studies found little to no difference in well-being for those in the intervention and control groups (SMD 0.02, 95% CI -0.08 to 0.13, small effect, low-certainty evidence), demonstrated by a mean change of 0.4 points on a scale with a range of 0 to 100. Adverse events related to the social media component of the interventions, such as privacy issues, were not reported in any of our included studies. We were unable to conduct planned subgroup analyses related to health equity as only four studies reported relevant data.

AUTHORS' CONCLUSIONS

This review combined data for a variety of outcomes and found that social media interventions that aim to increase physical activity may be effective and social media interventions may improve well-being. While we assessed many other outcomes, there were too few studies to compare or, where there were studies, the evidence was uncertain. None of our included studies reported adverse effects related to the social media component of the intervention. Future studies should assess adverse events related to the interactive social media component and should report on population characteristics to increase our understanding of the potential effect of these interventions on reducing health inequities.

Suicide-related Twitter Content in Response to a National Mental Health Awareness Campaign and the Association between the Campaign and Suicide Rates in Ontario

OBJECTIVE

Mental health awareness (MHA) campaigns have been shown to be successful in improving mental health literacy, decreasing stigma, and generating public discussion. However, there is a dearth of evidence regarding the effects of these campaigns on behavioral outcomes such as suicides. Therefore, the objective of this article is to characterize the association between the event and suicide in Canada's most populous province and the content of suicide-related tweets referencing a Canadian MHA campaign (Bell Let's Talk Day [BLTD]).

METHODS

Suicide counts during the week of BTLD were compared to a control window (2011 to 2016) to test for associations between the BLTD event and suicide. Suicide tweets geolocated to Ontario, posted in 2016 with the BLTD hashtag were coded for specific putatively harmful and protective content.

RESULTS

There was no associated change in suicide counts. Tweets (n = 3,763) mainly included content related to general comments about suicide death (68%) and suicide being a problem (42.8%) with little putatively helpful content such as stories of resilience (0.6%) and messages of hope (2.2%).

CONCLUSIONS

In Ontario, this national mental health media campaign was associated with a high volume of suicide-related tweets but not necessarily including content expected to diminish suicide rates. Campaigns like BLTD should strongly consider greater attention to suicide-related messaging that promotes help-seeking and resilience. This may help to further decrease stigmatization, and potentially, reduce suicide rates.

Management of a High-Performing Mental Health Recovery Research Group

A personal perspective is given on the processes involved in managing and sustaining a high-performing mental health recovery research group. The broader context of scholarship in the United Kingdom is outlined, in which academic productivity is commodified specifically in relation to peer-reviewed journal papers. Four leadership choices in developing a high-performing research group are discussed: optimal group size; sharing the workload; maintaining a programmatic focus; and performance expectations. Approaches to maximising innovation are identified, including emotional and intellectual engagement of team members, working with diverse stakeholders and convening communities of practice. We use a highly managed approach to publications from inception to acceptance, which is described in detail. The use of these approaches is illustrated in relation to the Recovery Research Team which was formed in 2009. Specific recovery-related issues covered include demonstrating the ability to develop a significant recovery research portfolio (our four current large [>UK£2 m] studies relate to recovery narratives, global mental health peer support work, digital interventions and Recovery Colleges); the positive implications of actively recruiting researchers with mental health lived experience; how performance issues are managed; our approach to involving lived experience co-authors in papers; and our decision to conduct mixed-methods rather than solely qualitative studies.

Mental health stigma in Ukraine: cross-sectional survey

BACKGROUND AND STUDY OBJECTIVES

This study aimed to assess among Ukrainian adults: (1) knowledge of mental disorders; (2) attitudes towards people with mental health disorders, and to the delivery of mental health treatment within the community; and (3) behaviours towards people with mental disorders.

METHODOLOGY

A cross-sectional survey of Ukrainian adults aged 18-60 was conducted. Stigma-related mental health knowledge was measured using the mental health knowledge schedule. Attitude towards people with mental health disorders was assessed using the Community Attitudes towards Mental Illness scale. The Reported and Intended Behaviour scale was used to assess past and future intended behaviour towards people with mental health disorders.

RESULTS

Associations between gender, age, and educational level and the knowledge and attitudes measures were identified. There was evidence of a positive association between being male and positive intended behaviours towards people with mental health disorders [mean difference (MD) = 0.509, 95% confidence interval (CI) 0.021-0.998]. Older age was negatively associated with positive intended behaviours towards people with mental health disorders (MD = -0.017, 95% CI 0.0733 to -0.001). Higher education was positively associated with stigma-related mental health knowledge (MD = 0.438, 95% CI 0.090-0.786), and negatively associated with authoritarian (MD = 0.755, 95% CI 0.295-1.215) attitudes towards people with mental health problems.

CONCLUSION

Overall, the findings indicate a degree of awareness of, and compassion towards, people with mental illness among Ukrainian adults, although this differed according to gender, region, and education level. Results indicate a need for the adoption and scaling-up of anti-stigma interventions that have been demonstrated to be effective.

Structural determinants of stigma across health and social conditions: a rapid review and conceptual framework to guide future research and intervention

INTRODUCTION

Stigma has been identified as a key determinant of health and health inequities because of its effects on access to health-enabling resources and stress exposure. Though existing reports offer in-depth summaries of the mechanisms through which stigma influences health, a review of evidence on the upstream drivers of stigma across health and social conditions has been missing. The objective of this review is to summarize known structural determinants of stigma experienced across health and social conditions in developed country settings.

METHODS

We conducted a rapid review of the literature. English- and French-language peer-reviewed and grey literature works published after 2008 were identified using MEDLINE, Embase, PsycINFO, Google and Google Scholar. Titles and abstracts were independently screened by two reviewers. Information from relevant publications was extracted, and a thematic analysis of identified determinants was conducted to identify broad domains of structural determinants. A narrative synthesis of study characteristics and identified determinants was conducted.

RESULTS

Of 657 publications identified, 53 were included. Ten domains of structural determinants of stigma were identified: legal frameworks, welfare policies, economic policies, social and built environments, media and marketing, pedagogical factors, health care policies and practices, biomedical technology, diagnostic frameworks and public health interventions. Each domain is defined and summarized, and a conceptual framework for how the identified domains relate to the stigma process is proposed.

CONCLUSION

At least 10 domains of structural factors influence the occurrence of stigma across health and social conditions. These domains can be used to structure policy discussions centred on ways to reduce stigma at the population level.

Reducing stigma and discrimination associated with COVID-19: early stage pandemic rapid review and practical recommendations

AIMS

To develop recommendations for strategies and interventions to reduce stigma and discrimination related to coronavirus disease 2019 (COVID-19), through reviewing and synthesising evidence in relation to COVID-19 and other disease outbreaks and infectious/stigmatised conditions from systematic reviews and primary studies and recommendations from additional materials.

METHODS

Rapid review, drawing on the World Health Organization's (WHO) methodology for developing interim guidelines during health emergencies. PubMed/MEDLINE, PsycINFO, Cochrane Central and Campbell Collaboration searched up to mid-April 2020. Searches were supplemented by reference-searching and expert recommendations. Searches were designed to identify: (1) systematic reviews (<10 years), or (2) primary intervention studies (no date limit) reporting evidence on anti-stigma interventions (in relation to COVID-19 or other infectious/stigmatised conditions) or (3) additional relevant materials. Data were extracted on population, intervention, outcome and results. These data were compiled into evidence summary tables and narrative overviews. Recommendations on strategies for COVID-19 stigma-reduction were developed using the WHO 'Evidence to Decision' framework approach. The review protocol was registered with PROSPERO (registration ID: CRD42020177677).

RESULTS

The searches identified a total of 4150 potentially relevant records, from which 12 systematic reviews and 29 additional articles were included. Overarching considerations and specific recommendations focus on: (1) language/words used in relation to COVID-19 and affected people; (2) media/journalistic practices; (3) public health interventions; (4) targeted public health interventions for key groups and (5) involving communities and key stakeholders.

CONCLUSIONS

These recommendations represent the first consolidated evidence-based guidance on stigma and discrimination reduction in relation to COVID-19. Mitigating the impact of stigma is critical in reducing distress and negative experiences, and strengthening communities' resolve to work together during exceptional circumstances. Ultimately, reducing stigma helps addressing structural inequalities that drive marginalisation and exacerbate both health risks and the impact of stigma. Administrations and decision makers are urged to consider integrating these recommendations into the ongoing COVID-19 response.

Association between Work Environments and Stigma towards People with Schizophrenia among Mental Health Professionals in Japan

This study aimed to examine the association between control over practice in work environments and stigma toward people with schizophrenia among mental health professionals. We conducted secondary analyses on data from a self-administered questionnaire survey. The sample in the initial study included mental health professionals from two psychiatric hospitals, 56 psychiatric clinics, and community service agencies in Japan. The Ethics Committee of the University of Tokyo, approved this study. Data from 279 participants were used for secondary analyses (valid response rate = 58.7%). The hierarchical multiple regression analysis was used to determine the association between control over practice and stigma. We performed subgroup analyses among nurses (n = 121) and psychiatric social workers (n = 92). Control over practice was negatively associated with stigma among mental health professionals (β = −0.162, p < 0.01). The subgroup analyses among nurses indicated that control over practice, educational history and recovery knowledge were associated with stigma. However, these variables were not associated with stigma among psychiatric social workers. Control over practice might help to reduce stigma among mental health professionals. Factors related to stigma might differ by occupation. Therefore, further comprehensive studies among various professionals would further our understanding of these factors.

A Call to Action. A Critical Review of Mental Health Related Anti-stigma Campaigns

Using a knowledge-attitudes-behavior practice (KABP) paradigm, professionals have focused on educating the public in biomedical explanations of mental illness. Especially in high-income countries, it is now common for education-based campaigns to also include some form of social contact and to be tailored to key groups. However, and despite over 20 years of high-profile national campaigns (e.g., Time to Change in England; Beyond Blue in Australia), examinations suggest that the public continue to Other those with experiences of mental ill-health. Furthermore, evaluations of anti-stigma programs are found to have weak- to no significant long-term effects, and serious concerns have been raised over their possible unintended consequences. Accordingly, this article critically re-engages with the literature. We evidence that there have been systematic issues in problem conceptualization. Namely, the KABP paradigm does not respond to the multiple forms of knowledge embodied in every life, often outside conscious awareness. Furthermore, we highlight how a singular focus on addressing the public's perceived deficits in professionalized forms of knowledge has sustained public practices which divide between "us" and "them." In addition, we show that practitioners have not fully appreciated the social processes which Other individuals with experiences of mental illness, nor how these processes motivate the public to maintain distance from those perceived to embody this devalued form of social identity. Lastly, we suggest methodological tools which would allow public health professionals to fully explore these identity-related social processes. Whilst some readers may be frustrated by the lack of clear solutions provided in this paper, given the serious unintended consequences of anti-stigma campaigns, we caution against making simplified statements on how to correct public health campaigns. Instead, this review should be seen as a call to action. We hope that by fully exploring these processes, we can develop new interventions rooted in the ways the public make sense of mental health and illness.

Relationships between types of UK national newspapers, illness classification, and stigmatising coverage of mental disorders

BACKGROUND

Media coverage on mental health problems has been found to vary by newspaper type, and stigma disproportionately affects people with mental illness by diagnosis.

OBJECTIVE

This study investigated the relationships between types of UK national newspaper (tabloid vs. broadsheet), illness classification (SMI-severe mental illnesses vs. CMD-common mental disorders), and stigmatising coverage of mental disorders, and whether these relationships changed over the course of the Time to Change anti-stigma programmes in England and Wales.

METHODS

Secondary analysis of data from a study of UK newspaper coverage of mental illness was performed. Relevant articles from nine UK national newspapers in 2008-11, 2013, 2016 and 2019 were retrieved. A structured coding framework was used for content analysis. The odds an article was stigmatising in a tabloid compared to a broadsheet, and about SMI compared to CMD, were calculated. Coverage of CMD and SMI by newspaper type was compared using the content elements categorised as stigmatising or anti-stigmatising.

RESULTS

2719 articles were included for analysis. Articles in tabloids had 1.32 times higher odds of being stigmatising than articles in broadsheet newspapers (OR 1.32, 95% CI 1.12-1.55). Odds of stigmatising coverage was 1.72 times higher for articles on SMI than CMD (OR  1.72, 95% CI 1.39-2.13). Different patterns in reporting were observed when results were stratified by years for all analyses. A few significant associations were observed for the portrays of stigmatising elements between tabloid and broadsheet newspapers regarding SMI or CMD.

CONCLUSIONS

Tailored interventions are needed for editors and journalists of different newspaper types, to include specific strategies for different diagnoses.

HIV Stigma and Its Associations with Longitudinal Health Outcomes Among Persons Living with HIV with a History of Unhealthy Alcohol Use

This study examined the demographic and clinical correlates of HIV stigma and evaluated how HIV stigma was associated with physical and mental health outcomes one year later in a primary-care based cohort of persons living with HIV (PLHIV; N = 584). HIV stigma was measured using a modified Berger HIV stigma scale, which includes four subscales: (1) personalized stigma; (2) disclosure concerns; (3) negative self-image; and (4) concerns around public attitudes towards PLHIV. Physical and mental health were assessed using the 12-item short form survey (SF-12). Compared to whites, African Americans were more likely to have higher personalized stigma scores (adjusted prevalence ratio [aPR] 1.54 [95% confidence interval 1.10-2.15]), disclosure concerns (aPR 1.40 [1.03-1.92]), and concerns with public attitudes about PLHIV (aPR 1.61 [1.11-2.34]). Hispanic/Latinx participants were more likely to have concerns around public attitudes towards PLHIV (aPR 1.50 [1.11-2.02]) than whites. Compared to men, women were more likely to have higher negative self-image scores (aPR 1.50 [1.08-2.08]). Higher stigma scores were associated with poorer subsequent self-reported physical and mental health functional status. Our findings highlight the substantial need for addressing HIV stigma, particularly among minority subgroups.

An Exploratory Analysis of the Portrayal of Mental Illness in Qatar's Newspapers

BACKGROUND

Concerns have been raised about the role of the media influencing the public's understanding of mental illness.

AIM

This study explored the extent and nature of mental health coverage in Qatar's newspapers. A secondary aim was to compare the mental health-related coverage with that of diabetes.

METHODS

This was a retrospective quantitative and qualitative analysis of textual data published in Qatari newspapers. Quantitative descriptive analysis was employed to determine the extent of media coverage while qualitative content analysis was employed to examine the discourse tone and assess the stigmatization of the main messages on the text.

RESULTS

A total of 659 mental health-related articles were published; the main focus of the articles was on autism, depression, and non-pharmacological therapies for mental illness. Analysis of the retrieved articles revealed a predominantly informative content, with mostly non-stigmatizing tone except for non-national news that often linked mental illness with dangerousness or violence. A higher number of articles with mental health-related content than about diabetes were found.

CONCLUSION

Although the newspaper content analysis revealed mostly a non-stigmatizing tone in mental health reporting in newspapers, there is a need to increase representation of people with mental illness in print media, increase awareness of the diversity of treatments available, and increase more scientific reporting to raise mental health literacy in Qatar.

Reducing Mental Health Stigma Through Identification With Video Game Avatars With Mental Illness

This study examines how playing a video game featuring a player-character with mental illness can positively impact mental illness stigma. We hypothesized that interactive gameplay would positively predict transportation into the story world. Then, transportation would predict identification with the main character. This identification should then reduce stigma in two ways: by lowering stereotyping and limiting participants’ desire for social distance. A two-factor, yoked experiment was designed utilizing Hellblade: Senua’s Sacrifice, a game praised for its accurate portrayal of psychosis. The main character, Senua, suffers from psychosis and must navigate her quest along with her own mental health. Players either played the first 45 min of the game or watched gameplay footage of other participants’ sessions. Transportation into the story world, identification with Senua, and the two aspects of stigma – stereotyping and social distance – were measured. Consistent with hypotheses, a structural equation model found an indirect path from gameplay to reduced social distance through first transportation and then identification. Players also reported higher levels of transportation than non-players, and that heightened transportation led to greater identification and then a lowered desire for social distance from the mentally ill. The indirect path to stereotyping was not significant. These results and implications are discussed in detail.

Core components of mental health stigma reduction interventions in low- and middle-income countries: a systematic review

AIMS

To identify and categorise core components of effective stigma reduction interventions in the field of mental health in low- and middle-income countries (LMICs) and compare these components across cultural contexts and between intervention characteristics.

METHODS

Seven databases were searched with a strategy including four categories of terms ('stigma', 'mental health', 'intervention' and 'low- and middle-income countries'). Additional methods included citation chaining of all papers identified for inclusion, consultation with experts and hand searching reference lists from other related reviews. Studies on interventions in LMICs aiming to reduce stigma related to mental health with a stigma-related outcome measure were included. All relevant intervention characteristics and components were extracted and a quality assessment was undertaken. A 'best fit' framework synthesis was used to organise data, followed by a narrative synthesis.

RESULTS

Fifty-six studies were included in this review, of which four were ineffective and analysed separately. A framework was developed which presents a new categorisation of stigma intervention components based on the included studies. Most interventions utilised multiple methods and of the 52 effective studies educational methods were used most frequently (n = 83), and both social contact (n = 8) and therapeutic methods (n = 3) were used infrequently. Most interventions (n = 42) based their intervention on medical knowledge, but a variety of other themes were addressed. All regions with LMICs were represented, but every region was dominated by studies from one country. Components varied between regions for most categories indicating variation between cultures, but only a minority of studies were developed in the local setting or culturally adapted.

CONCLUSIONS

Our study suggests effective mental health stigma reduction interventions in LMICs have increased in quantity and quality over the past five years, and a wide variety of components have been utilised successfully - from creative methods to emphasis on recovery and strength of people with mental illness. Yet there is minimal mention of social contact, despite existing strong evidence for it. There is also a lack of robust research designs, a high number of short-term interventions and follow-up, nominal use of local expertise and the research is limited to a small number of LMICs. More research is needed to address these issues. Some congruity exists in components between cultures, but generally they vary widely. The review gives an in-depth overview of mental health stigma reduction core components, providing researchers in varied resource-poor settings additional knowledge to help with planning mental health stigma reduction interventions.

Effects of messaging on public support for drug consumption rooms in scotland, UK

BACKGROUND

There is evidence to suggest that medically supervised drug consumption rooms (DCRs) may form part of responses to reduce drug-related harm. Although DCRs have been established globally, they are perceived by some to be a controversial approach in the UK, and Government has repeatedly rejected proposals to establish one in Glasgow, Scotland. As public support is an important component of policy development and enactment, we sought to investigate the effects of different types of message framing on public support for DCR.

METHODS

We undertook a cross-sectional online study with a randomised design, conducted with a nationally representative sample. Participants were randomised to one of six message conditions comprising combinations of four components. All conditions included i) a basic description of a DCR, and conditions included combinations of ii) factual information; iii) pre-emptive refutation of common public concerns about DCR; and/or iv) a sympathetic narrative describing a mother whose son died from a heroin overdose. After reading each message, participants completed a bespoke measure assessing support for DCR. Data were analysed using ANCOVA.

RESULTS

Complete data were obtained from 1591 participants (50.3% Female; mean age 44.9 ± 16.1 years). Compared to reading a basic description of DCR alone, there was greater support for DCR in participants receiving the refutation (p < .001); sympathetic + factual (p < .05); and sympathetic + factual + refutation (p < .001) message conditions. Presenting factual or sympathetic messages alone were not associated with increased support.

CONCLUSION

Our findings suggest that public support for DCRs is not improved through communication of factual statements outlining potential benefits of the intervention alone. Advocates seeking to foster public support, and thus influence policy making, should also consider communication campaigns that address common concerns that the public might have about DCRs, and present the intervention in relation to potential benefits that they hold for people indirectly affected by drug-related harm.

Promoting Recovery in Mental Illness: The Perspectives of Patients, Caregivers, and Community Members in Dar es Salaam, Tanzania

Background

Promoting mental health and care in the community setting leads to the recovery of patients with mental illness. Although recovery in mental health is a complex phenomenon, caregivers and community members have important roles to play in the recovery process for patients with mental illness. Little is documented on how recovery is promoted in the community setting. This study explored the experience of patients, caregivers, and community members on how recovery can be realized in a patient with severe mental illness in Dar es Salaam.

Methods

We conducted four focus group discussions (FGDs): two with caregivers and the other two with community members. Also, six in-depth interviews were held with patients with mental illness. Participants were purposively selected based on the type of information needed. Both FGD and in-depth interviews were digitally recorded and transcribed. Qualitative content analysis was used to analyze data. Findings. Four themes emerged from this study, which include promoting patients' participation in household activities, improving patients' support system, promoting patients' self-care management, and providing safety and protection among patients with mental illness. However, financial, psychological, and establishing care and support centers and professional supports emerged as subthemes from patients' support system.

Conclusion

Caregivers and community members are significant stakeholders for promoting recovery for people with mental illness. The current study reveals that patients' involvement in home activities, promoting self-care management, improving patients' support systems, and providing safety and protection are important factors that promote recovery for people with mental illness. Advocating mental health awareness for caregivers and community members will bridge the gap to enhance the recovery for people with mental illness. Further research is needed in this area to explore the health care providers' perspectives on the recovery process of mental illness in the hospital setting.

Mental health stigma and mental health knowledge in Chinese population: a cross-sectional study

BACKGROUND

Little is known about the public stigma on mental illness and mental health knowledge (MHK) in China, public stigma and low MHK can negatively affect patients' health and increase the burden of mental disorders on society. This study aimed at investigating the rates of stigma and MHK, the correlates of stigma and MHK, and the association between MHK and stigma among a Chinese population.

METHODS

The data is from the Tianjin Mental Health Survey (TJMHS), which involved a large and a representative sample of adult community residents in the Chinese municipality of Tianjin (n = 11,748). In a 12% random subsample (n = 1775) the Perceived Discrimination and Devaluation scale (PDD) and a Mental Health Knowledge Questionnaire (MHKQ) were administered. First, percentages of the responses to the individual items of the PDD and MHKQ were investigated. Second, sociodemographic correlates of PDD and MHK, and the association between stigma and MHK were investigated.

RESULTS

We found that a sizable proportion of participants responded that others would hold a negative attitude towards (former) mental patients, especially with regard to engaging in closer personal relationships. Most people were not familiar about the causes, treatments and prevention of mental illness. Resident area, age, education level, Per capita family income and employment status were related to devaluation score and MHKQ score. MHK was negatively associated with public stigma.

CONCLUSIONS

There is room for improvement with regard to levels of public stigma and MHK in China. Providing psychoeducation to improve public MHK could also contribute to reduction of public stigma.

Psychological impact of anti-Asian stigma due to the COVID-19 pandemic: A call for research, practice, and policy responses

The COVID-19 pandemic is linked to a rise in stigma and discrimination against Chinese and other Asians, which is likely to have a negative impact on mental health, especially when combined with additional outbreak-related stressors. We discuss the need to consider the potential harms of these anti-Asian sentiments during both the height of the pandemic and longer-term recovery through (a) research-examining how it affects mental health and recovery; (b) practice-implementing evidence-based stigma reduction initiatives; and (c) policy-coordinating federal response to anti-Asian racism including investment in mental health services and community-based efforts. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The Effectiveness of Two Potential Mass Media Interventions on Stigma: Video-Recorded Social Contact and Audio/Visual Simulations

Two approaches that may be particularly well suited for mass media (large scale) stigma interventions are video-recorded social contact and simulations, but research is rather limited. The purpose of this study was to evaluate two potential mass media interventions on different facets of stigma. Participants (N = 244) completed stigma measures prior to, immediately following, and 1 week following the random assignment of: (1) video-recorded social contact, (2) an audio/visual simulation, or (3) no intervention. The video-recorded social contact led to decreases on preference for social distance and negative emotions across 1 week, but only a temporary decrease on perceptions of dangerousness. In contrast, no significant changes in stigma were noted following the simulation. In sum, video-recorded social contact appears promising and offers many advantages for mass media implementation including low cost, minimal resources, and ease of dissemination. In contrast, further evaluation of audio/visual simulations is warranted before implementation.

Time to Change's social marketing campaign for a new target population: results from 2017 to 2019

BACKGROUND

Since 2009 Time to Change has included among its strategies a social marketing campaign to tackle the stigma surrounding mental health problems. At the start of its third phase (2016-2021) the target group of the campaign was kept as people aged between mid-twenties and mid-forties but changed to middle-low income groups and the content was focused on men.

METHODS

Participants (n = 3700) were recruited through an online market research panel, before and after each burst of the campaign. They completed an online questionnaire evaluating knowledge (Mental Health Knowledge Schedule, MAKS); attitudes (Community Attitudes toward Mental Illness, CAMI); and desire for social distance (Intended Behaviour subscale of the Reported and Intended Behaviour Scale, RIBS). Socio-demographic data and awareness of the campaign were also collected.

RESULTS

For each of the 3 bursts, significant pre-post awareness differences were found (OR = 2.83, CI = 1.90-4.20, p < 0.001; OR = 1.72, CI = 1.22-2.42, p = 0.002; OR = 1.41, CI = 1.01-1.97, p = 0.043), and awareness at the end of the third burst was 33%. Demographic factors associated with awareness for one or more bursts included having children, familiarity with mental illness, male sex, being Black, Asian or other ethnic minorities and living in London or the East Midlands regions. An improvement across bursts in the "living with" subscale item of the RIBS, and in the "recover" and "advice to a friend" MAKS items were found. Familiarity with mental illness had the strongest association with all outcome measures, while the awareness of the campaign was also related with higher scores in MAKS and RIBS.

CONCLUSIONS

These interim results suggest that the campaign is reaching and having an impact on its new target audience to a similar extent as did the TTC phase 1 campaign. While over the course of TTC we have found no evidence that demographic differences in stigma have widened, and indeed those by age group and region of England have narrowed, those for socioeconomic status, ethnicity and sex have so far remained unchanged. By targeting a lower socioeconomic group and creating relatively greater awareness among men and in Black and ethnic minority groups, the campaign is showing the potential to address these persistent differences in stigma.

The impact of mental health recovery narratives on recipients experiencing mental health problems: Qualitative analysis and change model

BACKGROUND

Mental health recovery narratives are stories of recovery from mental health problems. Narratives may impact in helpful and harmful ways on those who receive them. The objective of this paper is to develop a change model identifying the range of possible impacts and how they occur.

METHOD

Semi-structured interviews were conducted with adults with experience of mental health problems and recovery (n = 77). Participants were asked to share a mental health recovery narrative and to describe the impact of other people's recovery narratives on their own recovery. A change model was generated through iterative thematic analysis of transcripts.

RESULTS

Change is initiated when a recipient develops a connection to a narrator or to the events descripted in their narrative. Change is mediated by the recipient recognising experiences shared with the narrator, noticing the achievements or difficulties of the narrator, learning how recovery happens, or experiencing emotional release. Helpful outcomes of receiving recovery narratives are connectedness, validation, hope, empowerment, appreciation, reference shift and stigma reduction. Harmful outcomes are a sense of inadequacy, disconnection, pessimism and burden. Impact is positively moderated by the perceived authenticity of the narrative, and can be reduced if the recipient is experiencing a crisis.

CONCLUSIONS

Interventions that incorporate the use of recovery narratives, such as peer support, anti-stigma campaigns and bibliotherapy, can use the change model to maximise benefit and minimise harms from narratives. Interventions should incorporate a diverse range of narratives available through different mediums to enable a range of recipients to connect with and benefit from this material. Service providers using recovery narratives should preserve authenticity so as to maximise impact, for example by avoiding excessive editing.

Association between attitudes of stigma toward mental illness and attitudes toward adoption of evidence-based practice within health care providers in Bahrain

The health care system is one of the key areas where people with mental illnesses could experience stigma. Clinicians can hold stigma attitudes during their interactions with patients with mental illness. To improve the quality of mental health services and primary care, evidence-based practices should be disseminated and implemented. In this study, we evaluated the attitudes of health care providers in Bahrain toward people with mental illness and adoption of evidence-based practice using the Opening Minds Stigma Scale for Healthcare Providers (OMS-HC) and Evidence-Based Practice Attitude Scale (EBPAS). We conducted a cross-sectional study across 12 primary health care centers and a psychiatric hospital (the country's main mental health care facility). A self-report questionnaire was distributed among all health care providers. A total of 547 health care providers participated, with 274 from mental health services and 273 from primary care services. Results of the OMS-HC indicated differences between both main groups and subgroups. Regression model analysis reported significant outcomes. There was no statistical difference found between both groups in EBPAS scores. A weak but statistically significant negative association was reported between both scales. Participants showed varying stigma attitudes across different working environments, with less stigma shown in mental health services than in primary care services. Providers who were more open to adopting evidence-based practices showed less stigma toward people with mental illness. Comparing our findings with previous research showed that health care providers in Bahrain hold more stigma attitudes than other groups studied. We hope that this study serves as an initial step toward future campaigns against the stigma of mental illness in Bahrain and across the region.

Determinants of treatment of mental disorders in Lebanon: barriers to treatment and changing patterns of service use

AIMS

To investigate for the first time the determinants and barriers of seeking help for mental disorders in the Arab world based on a national study: Lebanese Evaluation of the Burden of Ailments and Needs Of the Nation (L.E.B.A.N.O.N).

METHODS

A nationally representative (n = 2857) and multistage clustered area probability household sample of adults ≥18 years and older was assessed for lifetime and 12 months mental disorders using the Composite International Diagnostic Interview. In addition, detailed information was obtained on help- seeking behaviour and barriers to treatment.

RESULTS

In total, 19.7% of the Lebanese with mental disorders sought any type of treatment: 91% of those who sought treatment did so within the health sector. Severity and perceived severity of disorders predicted seeking help, the highest being for panic disorder. The greatest barrier to seek help was low perceived need for treatment (73.9%). Stigma was reported to be a factor only in 5.9% of those who thought about seeking treatment. Eighty per cent of the Lebanese reported they would not be embarrassed if friends knew they were seeking help from a professional.

CONCLUSIONS

A small fraction of Lebanese seek help for their mental health problems: female gender, higher education and income are predictors of positive attitudes to help seeking. Severity and recognition of disorders, more than stigma, to get treatment seem to be the most important factors in determining help seeking. The findings underscore the importance of helping the public recognise mental health disorders.

Changes in Stigma Experience Among Mental Health Service Users over Time: A Qualitative Study with Focus Groups

Public expenditure on mental health education has grown exponentially in the past two decades. A qualitative study using focus groups was used to explore whether the experience of stigma among 22 mental health service users improved over time. We identified five major themes on changes in social stigma, perceived stigma, and stigma coping. Stigmatizing and discriminatory experiences were still common in workplace, healthcare system, and relational aspects but some participants perceived that there were reductions in social stigma. Participants believed that media portrayal and celebrity effect were important in fostering greater acceptance toward people with mental illness and the importance of family support and stigma resistance for minimizing the harmful impacts of stigma. The findings are important in the future design of public educational and stigma reduction programs.