Addressing Mental Health Stigma in Low-Income and Middle-Income Countries: A New Frontier for Digital Mental Health

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.

Digital Mental Health Interventions for Adolescents in Low- and Middle-Income Countries: Scoping Review

BACKGROUND

Digital mental health interventions (DMHIs) are increasingly recognized as potential solutions for adolescent mental health, particularly in low- and middle-income countries (LMICs). The United Nations' Sustainable Development Goals and universal health coverage are instrumental tools for achieving mental health for all. Within this context, understanding the design, evaluation, as well as the barriers and facilitators impacting adolescent engagement with mental health care through DMHIs is essential.

OBJECTIVE

This scoping review aims to provide insights into the current landscape of DMHIs for adolescents in LMICs.

METHODS

The Joanna Briggs Institute scoping review methodology was used, following the recommendations of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). Our search strategy incorporated 3 key concepts: population "adolescents," concept "digital mental health interventions," and context "LMICs." We adapted this strategy for various databases, including ACM Digital Library, APA PsycINFO, Cochrane Library, Google Scholar (including gray literature), IEEE Xplore, ProQuest, PubMed (NLM), ScienceDirect, Scopus, and Web of Science. The articles were screened against a specific eligibility criterion from January 2019 to March 2024.

RESULTS

We analyzed 20 papers focusing on DMHIs for various mental health conditions among adolescents, such as depression, well-being, anxiety, stigma, self-harm, and suicide ideation. These interventions were delivered in diverse formats, including group delivery and self-guided interventions, with support from mental health professionals or involving lay professionals. The study designs and evaluation encompassed a range of methodologies, including randomized controlled trials, mixed methods studies, and feasibility studies.

CONCLUSIONS

While there have been notable advancements in DMHIs for adolescents in LMICs, the research base remains limited. Significant knowledge gaps persist regarding the long-term clinical benefits, the maturity and readiness of LMIC digital infrastructure, cultural appropriateness, and cost-effectiveness across the heterogeneous LMIC settings. Addressing these gaps necessitates large-scale, co-designed, and culturally sensitive DMHI trials. Future work should address this.

Coping strategies mediated the relationship between perceived stress and hair cortisol among socioeconomically marginalized parents

Objective

This study aimed to (1) examine coping strategies and their relationship with demographics, perceived stress, and hair cortisol; and (2) explore whether coping partially mediated the relationship between perceived stress and hair cortisol.

Methods

Baseline data from 191 socioeconomically marginalized parents enrolled in two community-based clinical trials were used. The IBM SPSS Statistics Version 27 and Mplus Version 8 were used for data analyses.

Results

Parents' engagement in various coping strategies differed by age, ethnicity, race, marital status, education level, and number of children living in the household. Parents' use of problem-focused (instrumental support, planning), emotion-focused (venting, self-blame), and avoidant coping (self-distraction, denial, behavioral disengagement) increased from having low to moderate stress. However, when perceived stress increased from moderate to high, their use of emotion-focused and avoidant coping increased significantly, but problem-focused coping did not. Emotion-focused coping lowered the influence of perceived stress on hair cortisol, while avoidant coping increased the relationship between perceived stress and hair cortisol.

Conclusions

Although needing future investigation with longitudinal studies, the results suggest the need of promoting adaptive emotion-focused coping (emotional support, venting, and humor) to help socioeconomically marginalized parents manage their appraised overwhelming and uncontrollable stressors of food, house, and income insecurity.

Improving access to evidence-based interventions for trauma-exposed adults in low- and middle-income countries

In low- and middle-income countries (LMICs), the mental health consequences of trauma exposure pose a substantial personal, societal, and economic burden. Yet, the significant need for evidence-based mental health treatment remains largely unmet. To unlock the potential for mental health care for trauma survivors in lower-resource contexts, it is critical to map treatment barriers and identify strategies to improve access to evidence-based, culturally appropriate, and scalable interventions. This review, based on an International Society for Traumatic Stress (ISTSS) briefing paper, describes the treatment gap facing adults with traumatic stress in LMICs and identifies the barriers that contribute to this gap. We then highlight strategies for enhancing access to effective treatments for these populations, including task-sharing, the use of culturally adapted and multiproblem interventions, and digital tools to scale access to appropriate care. Finally, we offer recommendations for policymakers, researchers, and service providers to guide an agenda for action to close the treatment gap for trauma survivors in LMICs.

Nursing Students' Attitudes toward Working in Mental Health Facilities in Saudi Arabia: A Cross-Sectional Study

(1) Background: There is a global demand for more psychiatric nurses, with nursing students' attitudes toward mental illness and working in mental health facilities playing a pivotal role in their career choices. This study aims to evaluate attitudes toward working in mental health facilities among undergraduate nursing students in Saudi Arabia, both before and after exposure to psychiatry courses, and examine their relationship with perceptions of mental illness. (2) Methods: A quantitative descriptive and correlational cross-sectional design was employed. Nursing students' attitudes toward working in mental health facilities were assessed using the Attitude Toward Psychiatry 18 (ATP-18) questionnaire and the Beliefs Toward Mental Illness (BMI) scale. (3) Results: No significant relationship has been found between the frequency of negative views of both ATP-18 and BMI, and exposure to the psychiatry course. However, nurses who completed the psychiatry course held more positive views towards psychiatrists and found psychiatric patients less demanding, were less likely to view psychological disorders as dangerous, more confident in trusting mentally ill colleagues, and felt less embarrassed by the term "psychological disorder" compared to those who had not taken the course. (4) Conclusion: Based on our findings, it is evident that exposure to psychiatric courses and training enhances the potential of nursing students to contribute effectively to the psychiatric field. Therefore, integrating mental health and illness community services training into nursing education programs can play a pivotal role in raising awareness and attracting students who may hold negative attitudes towards individuals with mental illness.

Patient Adherence to a Real-World Digital, Asynchronous Weight Loss Program in Australia That Combines Behavioural and GLP-1 RA Therapy: A Mixed Methods Study

Increasingly large numbers of people are using digital weight loss services (DWLSs) to treat being overweight and obesity. Although it is widely agreed that digital modalities improve access to care in general, obesity stakeholders remain concerned that many DWLSs are not comprehensive or sustainable enough to deliver meaningful health outcomes. This study adopted a mixed methods approach to assess why and after how long patients tend to discontinue Australia's largest DWLS, a program that combines behavioural and pharmacological therapy under the guidance of a multidisciplinary care team. We found that in a cohort of patients who commenced the Eucalyptus DWLS between January and June 2022 (n = 5604), the mean program adherence was 171.2 (±158.2) days. Inadequate supplying of a patient's desired glucose-like peptide-1 receptor agonist medication was the most common reason for discontinuation (43.7%), followed by program cost (26.2%), result dissatisfaction (9.9%), and service dissatisfaction (7.2%). Statistical tests revealed that ethnicity and age both had a significant effect on patient adherence. These findings suggest that DWLSs have the potential to improve access to comprehensive, continuous obesity care, but care models need to improve upon the one observed in the Eucalyptus Australia DWLS to mitigate common real-world program attrition factors.

Investigating the spatiotemporal patterns and clustering of attendances for mental health services to inform policy and resource allocation in Thailand

BACKGROUND

Mental illness poses a substantial global public health challenge, including in Thailand, where exploration of access to mental health services is limited. The spatial and temporal dimensions of mental illness in the country are not extensively studied, despite the recognized association between poor mental health and socioeconomic inequalities. Gaining insights into these dimensions is crucial for effective public health interventions and resource allocation.

METHODS

This retrospective study analyzed mental health service utilization data in Thailand from 2015 to 2023. Temporal trends in annual numbers of individuals visiting mental health services by diagnosis were examined, while spatial pattern analysis employed Moran's I statistics to assess autocorrelation, identify small-area clustering, and hotspots. The implications of our findings for mental health resource allocation and policy were discussed.

RESULTS

Between 2015 and 2023, mental health facilities documented a total of 13,793,884 visits. The study found anxiety, schizophrenia, and depression emerged as the top three illnesses for mental health visits, with an increase in patient attendance following the onset of the COVID-19 outbreak. Spatial analysis identified areas of significance for various disorders across different regions of Thailand. Positive correlations between certain disorder pairs were found in specific regions, suggesting shared risk factors or comorbidities.

CONCLUSIONS

This study highlights spatial and temporal variations in individuals visiting services for different mental disorders in Thailand, shedding light on service gaps and socioeconomic issues. Addressing these disparities requires increased attention to mental health, the development of appropriate interventions, and overcoming barriers to accessibility. The findings provide a baseline for policymakers and stakeholders to allocate resources and implement culturally responsive interventions to improve mental health outcomes.

"Anxiety is not cute" analysis of twitter users' discourses on romanticizing mental illness

BACKGROUND

The proliferation of social media platforms has provided a unique space for discourse on mental health, originally intended to destigmatize mental illness. However, recent discourses on these platforms have shown a concerning shift towards the romanticization of mental health issues. This research focuses on Twitter (now called X) users' authentic discussions on the phenomenon of romanticizing mental health, aiming to uncover unique perspectives, themes, and language used by users when engaging with this complex topic.

METHODS

A comprehensive content analysis was conducted on 600 relevant tweets, with the application of topic modeling techniques. This methodology allowed for the identification and exploration of six primary themes that emerged from Twitter users' discussions. Statistical tests were not applied in this qualitative analysis.

RESULTS

The study identified six primary themes resulting from Twitter users' discussions on the romanticization of mental health. These themes include rejecting/critiquing the glamorization of mental health, monetization of mental health by corporate organizations, societal misconceptions of mental health, the role of traditional media and social media, unfiltered realities of depression, and the emphasis on not romanticizing mental health.

CONCLUSIONS

This study provides valuable insights into the multifaceted discourses surrounding the romanticization of mental health on Twitter. It highlights users' critiques, concerns, and calls for change, emphasizing the potential harm caused by romanticizing mental illness. The findings underscore the importance of fostering responsible and empathetic discussions about mental health on social media platforms. By examining how Twitter users interact with and respond to the romanticization of mental health, this research advances our understanding of emerging perspectives on mental health issues among social media users, particularly young adolescents. The study also underscores the effects of this phenomenon on individuals, society, and the mental health community. Overall, this research emphasizes the need for more responsible and knowledgeable discussions around mental health in the digital age.

Digital psychiatry in low-and-middle-income countries: New developments and the way forward

Low- and middle-income countries (LMICs) bear the greater share of the global mental health burden but are ill-equipped to deal with it because of severe resource constraints leading to a large treatment gap. The remote provision of mental health services by digital means can effectively augment conventional services in LMICs to reduce the treatment gap. Digital psychiatry in LMICs has always lagged behind high-income countries, but there have been encouraging developments in the last decade. There is increasing research on the efficacy of digital psychiatric interventions. However, the evidence is not adequate to conclude that digital psychiatric interventions are invariably effective in LMICs. A striking development has been the rise in mobile and smartphone ownership in LMICs, which has driven the increasing use of mobile technologies to deliver mental health services. An innovative use of mobile technologies has been to optimize task-shifting, which involves delivering mental healthcare services in community settings using non-specialist health professionals. Emerging evidence from LMICs shows that it is possible to use digital tools to train non-specialist workers effectively and ensure that the psychosocial interventions they deliver are efficacious. Despite these promising developments, many barriers such as service costs, underdeveloped infrastructure, lack of trained professionals, and significant disparities in access to digital services impede the progress of digital psychiatry in LMICs. To overcome these barriers, digital psychiatric services in LMICs should address contextual factors influencing the delivery of digital services, ensure collaboration between different stakeholders, and focus on reducing the digital divide.

A WHO digital intervention to address depression among young Chinese adults: a type 1 effectiveness-implementation randomized controlled trial

Common mental disorders among young people are rising globally. Current university-based interventions are inadequate to address the need for evidence-based interventions. We investigated the effectiveness and implementation of Step-by-Step (SbS), a WHO digital intervention to address depression, among Chinese university students with depressive symptoms. In this paper, we report a type 1 hybrid effectiveness-implementation randomized controlled trial conducted between September 2021 and September 2022. The control condition was enhanced treatment as usual (ETAU, psychoeducation). The primary outcome was improvement in depression symptoms. Secondary outcomes were improvements in psychological well-being, anxiety symptoms, and self-identified psychosocial problems. Effectiveness of the intervention was evaluated using generalized linear mixed models. Implementation outcomes were evaluated by thematic analysis of participant interviews. A total of 371 participants were enrolled to two treatment conditions in a 1:1 ratio. SbS resulted in a greater reduction in depressive symptoms at posttreatment (p = 0.004, Hedges' g = 0.35), but no significant difference between SbS and ETAU was observed at three-month follow-up (p = 0.179, Hedges' g = 0.16). The treatment effect was larger among those who adhered to the treatment (Hedges' gs = 0.59 and 0.30). Subjective well-being also improved for SbS at both time points (Hedges' gs = 0.31 and 0.30). In addition, SbS resulted in more improvement in anxiety symptoms at posttreatment (p = 0.029, Hedges' g = 0.26), but not at three-month follow-up (p = 0.265, Hedges' g = 0.13). The qualitative results demonstrated that the intervention was well-implemented as a self-help mental health service, with minimal support from peer supporters. In conclusion, Step-by-Step, a digital intervention developed by WHO, was effective in reducing depressive symptoms in the short term and improving psychological well-being in a longer term. The sustained effect on depression needs further investigation. Improving uptake and engagement in the program is needed for its scale-up implementation as a university-based mental health service for Chinese young adults. Trial registration: ChiCTR2100050214.

Navigating Mental Health: Community Members' Insights into Social Support and Inclusion in Matsafeni Village in Mbombela, Mpumalanga Province-A Qualitative Study

Mental health illnesses are increasingly prevalent worldwide, and South Africa is no exception. The research investigates the vital significance of social support in enhancing the welfare of individuals dealing with mental disorders. An essential aspect involves comprehending the interplay of emotional and practical supports provided by both families and the larger community. This study aims to explore community perceptions regarding social support and the involvement of individuals diagnosed with mental illnesses in Matsafeni Village. The research employed the qualitative method and descriptive exploratory research design, enabling the researchers to explore social support and the involvement of individuals with mental health disorders. Data were collected through unstructured, open-ended interviews, and participants were selected using a convenience sampling method. A total of only 15 participants were enrolled in this study, with variations in their educational backgrounds. Notably, only two participants had firsthand experiences with family members facing mental disorders. The study underscored the critical roles of family and community supports for individuals diagnosed with mental health disorders. The participants emphasized the necessity of mentally ill individuals receiving support from their loved ones and the broader community. Furthermore, they highlighted the importance for including individuals with mental health disorders in community activities as a means of better managing their conditions. The findings of this study can serve as a foundation for developing interventions to assist and support individuals affected by mental health disorders. Policymakers can also utilize the information to formulate strategies and best practices for promoting mental health awareness within the community.

Stress Alleviation Methods for community-Based Health ActiVists (SAMBHAV): Development of a digital program for stress reduction for community health workers in rural India

Background

Community health workers (CHWs) face high levels of stress (both professional and personal) and risk of burnout, highlighting the need for efforts to promote their mental health and well-being. This study seeks to develop a digital stress reduction program for CHWs in rural India.

Methods

A stepwise design process was employed to adapt and digitize the evidence-based World Health Organization's Self-Help Plus (SH+) intervention for addressing psychological distress among CHWs in Madhya Pradesh, India. This involved participatory design workshops with CHWs to ensure that the digital stress reduction intervention would be relevant for their needs and the local culture and context. Small groups of CHWs reviewed the adapted program content, allowing the research team to make refinements such as simplifying language, tailoring content to the local setting, and ensuring that program materials are both interesting and relevant. Simultaneously, the research team digitized the content, leveraging a combination of video and graphical content, and uploaded it to the Sangath Learning Management System, a digital platform accessible on a smartphone app.

Results

In total, 18 CHWs contributed to the adaptation of the SH+ content and digital intervention development. Participants commented on finding some terms difficult to follow and recommended simplifying the language and providing detailed explanations. Participants offered positive feedback on the adapted content, expressing that they found the examples covered in the material both relatable and relevant to their own personal experiences at home and in the workplace. By combining participants' insights and comments with feedback from content experts, it was possible to finalize a digital Hindi version of the SH+ intervention for CHWs in rural India.

Conclusions

This study is timely given the continued detrimental impacts of the COVID-19 pandemic, and offers a promising and potentially scalable digital program to alleviate psychological distress among frontline health workers.

Outrage and algorithms: Shifting drug-related stigma in a digital world

Illicit drug dependence is one of the most stigmatised health conditions worldwide and the harmful impacts of stigma for people who use drugs are well documented. The use of stigmatising language about drugs in traditional media is also well documented. The increasing use of digital media platforms has revolutionised the way we communicate, and extended the reach of our messages. However, there are issues specific to the ways in which these platforms operate that have the potential to increase drug-related stigma. This paper outlines the importance of language, narrative, and imagery in reducing this stigma. It discusses the challenges digital media platforms present to achieving this goal, including the use of engagement strategies that trigger fear and increase stigma, the potential for amplifying stigmatising messages by using algorithms, and the potential for dissemination of misinformation. Key strategies to frame conversations about drug use are presented including 1) appeal to values of fairness and equity rather than scaring people; 2) avoid correcting misinformation as it strengthens unhelpful stigmatising frames of drug use; and 3) create a new narrative, focusing on the diversity of experiences of people who use drugs. Internationally we are at a critical juncture with respect to drug policy reform, and efforts to reduce drug-related stigma are central to building support for these reforms. The extensive reach of digital media platforms represents an important opportunity to communicate about illicit drug use. The challenge is to do so in a way that minimises stigma. If we are to achieve change, a narrative that puts values, people, health care and equity at the centre of the conversation is critical.

User-Centered Design of a Gamified Mental Health App for Adolescents in Sub-Saharan Africa: Multicycle Usability Testing Study

BACKGROUND

There is an urgent need for scalable psychological treatments to address adolescent depression in low-resource settings. Digital mental health interventions have many potential advantages, but few have been specifically designed for or rigorously evaluated with adolescents in sub-Saharan Africa.

OBJECTIVE

This study had 2 main objectives. The first was to describe the user-centered development of a smartphone app that delivers behavioral activation (BA) to treat depression among adolescents in rural South Africa and Uganda. The second was to summarize the findings from multicycle usability testing.

METHODS

An iterative user-centered agile design approach was used to co-design the app to ensure that it was engaging, culturally relevant, and usable for the target populations. An array of qualitative methods, including focus group discussions, in-depth individual interviews, participatory workshops, usability testing, and extensive expert consultation, was used to iteratively refine the app throughout each phase of development.

RESULTS

A total of 160 adolescents from rural South Africa and Uganda were involved in the development process. The app was built to be consistent with the principles of BA and supported by brief weekly phone calls from peer mentors who would help users overcome barriers to engagement. Drawing on the findings of the formative work, we applied a narrative game format to develop the Kuamsha app. This approach taught the principles of BA using storytelling techniques and game design elements. The stories were developed collaboratively with adolescents from the study sites and included decision points that allowed users to shape the narrative, character personalization, in-app points, and notifications. Each story consists of 6 modules ("episodes") played in sequential order, and each covers different BA skills. Between modules, users were encouraged to work on weekly activities and report on their progress and mood as they completed these activities. The results of the multicycle usability testing showed that the Kuamsha app was acceptable in terms of usability and engagement.

CONCLUSIONS

The Kuamsha app uniquely delivered BA for adolescent depression via an interactive narrative game format tailored to the South African and Ugandan contexts. Further studies are currently underway to examine the intervention's feasibility, acceptability, and efficacy in reducing depressive symptoms.

The Use of Mobile Assessments for Monitoring Mental Health in Youth: Umbrella Review

BACKGROUND

Improving mental health in youth is a major concern. Future approaches to monitor and intervene in youth mental health problems should rely on mobile tools that allow for the daily monitoring of mental health both actively (eg, using ecological momentary assessments [EMAs]) and passively (eg, digital phenotyping) by capturing individuals' data.

OBJECTIVE

This umbrella review aims to (1) report the main characteristics of existing reviews on mental health and young people, including mobile approaches to mental health; (2) describe EMAs and trace data and the mental health conditions investigated; (3) report the main results; and (4) outline promises, limitations, and directions for future research.

METHODS

A systematic literature search was carried out in 9 scientific databases (Communication & Mass Media Complete, Psychology and Behavioral Sciences Collection, PsycINFO, CINAHL, ERIC, MEDLINE, the ProQuest Sociology Database, Web of Science, and PubMed) on January 30, 2022, coupled with a hand search and updated in July 2022. We included (systematic) reviews of EMAs and trace data in the context of mental health, with a specific focus on young populations, including children, adolescents, and young adults. The quality of the included reviews was evaluated using the AMSTAR (Assessment of Multiple Systematic Reviews) checklist.

RESULTS

After the screening process, 30 reviews (published between 2016 and 2022) were included in this umbrella review, of which 21 (70%) were systematic reviews and 9 (30%) were narrative reviews. The included systematic reviews focused on symptoms of depression (5/21, 24%); bipolar disorders, schizophrenia, or psychosis (6/21, 29%); general ill-being (5/21, 24%); cognitive abilities (2/21, 9.5%); well-being (1/21, 5%); personality (1/21, 5%); and suicidal thoughts (1/21, 5%). Of the 21 systematic reviews, 15 (71%) summarized studies that used mobile apps for tracing, 2 (10%) summarized studies that used them for intervention, and 4 (19%) summarized studies that used them for both intervention and tracing. Mobile tools used in the systematic reviews were smartphones only (8/21, 38%), smartphones and wearable devices (6/21, 29%), and smartphones with other tools (7/21, 33%). In total, 29% (6/21) of the systematic reviews focused on EMAs, including ecological momentary interventions; 33% (7/21) focused on trace data; and 38% (8/21) focused on both. Narrative reviews mainly focused on the discussion of issues related to digital phenotyping, existing theoretical frameworks used, new opportunities, and practical examples.

CONCLUSIONS

EMAs and trace data in the context of mental health assessments and interventions are promising tools. Opportunities (eg, using mobile approaches in low- and middle-income countries, integration of multimodal data, and improving self-efficacy and self-awareness on mental health) and limitations (eg, absence of theoretical frameworks, difficulty in assessing the reliability and effectiveness of such approaches, and need to appropriately assess the quality of the studies) were further discussed.

TRIAL REGISTRATION

PROSPERO CRD42022347717; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=347717.

Mental illness stigma in Bangladesh: Findings from a cross-sectional survey

Background

Mental illness stigma is universally prevalent and a significant barrier to achieving global mental health goals. Mental illness stigma in Bangladesh has gained little attention despite its widespread impact on seeking mental health care in rural and urban areas. This study aimed to investigate mental illness stigma and the associated factors in rural and urban areas of Bangladesh.

Methods

The study areas were divided into several clusters from which 325 participants (≥18 years) were recruited with systematic random sampling. The Bangla version of the Days' Mental Illness Stigma Scale was used to collect data. Independent-samples t-test, ANOVA, and multiple regression were performed.

Results

Results suggest that gender, age, geographical location, socioeconomic status, and occupation significantly differed across subscales of stigma. Age, gender, seeking treatment of mental illness, having knowledge on mental health, and socioeconomic status were predictive factors of mental illness stigma. The results also showed a high treatment gap in both rural and urban areas.

Conclusion

This study supports that mental illness stigma is prevalent in Bangladesh, requiring coordinated efforts. Results can inform the development of contextually tailored mental health strategies to reduce stigma and contribute to the promotion of mental health of individuals and communities across Bangladesh.

The Role of Moderators in Facilitating and Encouraging Peer-to-Peer Support in an Online Mental Health Community: A Qualitative Exploratory Study

Online peer support platforms have gained popularity as a potential way for people struggling with mental health problems to share information and provide support to each other. While these platforms can offer an open space to discuss emotionally difficult issues, unsafe or unmoderated communities can allow potential harm to users by spreading triggering content, misinformation or hostile interactions. The purpose of this study was to explore the role of moderators in these online communities, and how moderators can facilitate peer-to-peer support, while minimizing harms to users and amplifying potential benefits. Moderators of the Togetherall peer support platform were recruited to participate in qualitative interviews. The moderators, referred to as 'Wall Guides', were asked about their day-to-day responsibilities, positive and negative experiences they have witnessed on the platform and the strategies they employ when encountering problems such as lack of engagement or posting of inappropriate content. The data were then analyzed qualitatively using thematic content analysis and consensus codes were deduced and reviewed to reach final results and representative themes. In total, 20 moderators participated in this study, and described their experiences and efforts to follow a consistent and shared protocol for responding to common scenarios in the online community. Many reported the deep connections formed by the online community, the helpful and thoughtful responses that members give each other and the satisfaction of seeing progress in members' recovery. They also reported occasional aggressive, sensitive or inconsiderate comments and posts on the platform. They respond by removing or revising the hurtful post or reaching out to the affected member to maintain the 'house rules'. Lastly, many discussed strategies they elicit to promote engagement from members within the community and ensure each member is supported through their use of the platform. This study sheds light on the critical role of moderators of online peer support communities, and their ability to contribute to the potential benefits of digital peer support while minimizing risks to users. The findings reported here accentuate the importance of having well-trained moderators on online peer support platforms and can guide future efforts to effectively train and supervise prospective peer support moderators. Moderators can become an active 'shaping force' and bring a cohesive culture of expressed empathy, sensitivity and care. The delivery of a healthy and safe community contrasts starkly with non-moderated online forums, which can become unhealthy and unsafe as a result.

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.

Status of stigma on the health care workers related to COVID-19 at the first wave of the pandemic in Iran: A qualitative study

Background

Stigma can be seen as a mark of disgrace that can lead to the separation of one person from another. In this qualitative study, we assess the status of stigma among in front-line health care workers (HCWs) during the first wave of the COVID-19 pandemic in Iran.

Subjects and methods

The participants were selected from frontline HCWs related to COVID-19 in Imam Ali and Imam Hossein referral hospitals in Alborz province, Iran. Study was conducted between May and June 2020. The 32-item checklist Consolidated Criteria for Reporting Qualitative Research (COREQ) was used to report this qualitative study. Interview questions were prepared based on the grounded theory method. The thematic approach was used to analyze the data content. Data analysis was based on open and axial coding and after implementing the codes in MAXQDA software.

Results

The results of this study included 4 themes, 8 categories and 33 sub-categories. Themes included extrinsic and intrinsic elements of stigma, perplexity and stigma removal requirements. Extrinsic elements included "creating blame and shame" and "discrimination" categories. Intrinsic elements included "the desire to be avoidance," "feeling depressed and frustrated" and "feeling anxious and scared" categories. Perplexity included "feeling loss" category. Stigma removal requirements included "factors causing stigma" and "protective agents against stigma" categories.

Conclusion

Low public awareness on COVID-19 and inadequate public care, limited personal protective equipment and inadequate facilities for HCWs along with lack of appreciation for their efforts, lack of proper psychiatric/psychological counseling to identify and treat symptoms associated with mental health and the limitations of training to maintain mental health skills are considered to be factors in the formation of stigma among HCWs related to COVID-19. Health policymakers should implement coherent strategies related to increasing public awareness and providing personal protection needs and counseling care for HCWs in relation to COVID-19.

Effects of Internet-based Storytelling Programs (Amazing Adventure Against Stigma) in Reducing Mental Illness Stigma with Mediation by Interactivity and Stigma Content: A Randomized Controlled Trial (Preprint)

Background

Mental illness stigma has been a global concern, owing to its adverse effects on the recovery of people with mental illness, and may delay help-seeking for mental health because of the concern of being stigmatized. With technological advancement, internet-based interventions for the reduction of mental illness stigma have been developed, and these effects have been promising.

Objective

This study aimed to examine the differential effects of internet-based storytelling programs, which varied in the levels of interactivity and stigma content, in reducing mental illness stigma.

Methods

Using an experimental design, this study compared the effects of 4 storytelling websites that varied in the levels of interactivity and stigma content. Specifically, the conditions included an interactive website with stigma-related content (combo condition), a noninteractive website with stigma-related content (stigma condition), an interactive website without stigma-related content (interact condition), and a noninteractive website without stigma-related content (control condition). Participants were recruited via mass emails to all students and staff of a public university and via social networking sites. Eligible participants were randomized into the following four conditions: combo (n=67), stigma (n=65), interact (n=64), or control (n=67). The participants of each group viewed the respective web pages at their own pace. Public stigma, microaggression, and social distance were measured on the web before the experiment, after the experiment, and at the 1-week follow-up. Perceived autonomy and immersiveness, as mediators, were assessed after the experiment.

Results

Both the combo (n=66) and stigma (n=65) conditions were effective in reducing public stigma and microaggression toward people with mental illness after the experiment and at the 1-week follow-up. However, none of the conditions had significant time×condition effects in reducing the social distance from people with mental illness. The interact condition (n=64) significantly reduced public stigma after the experiment (P=.02) but not at the 1-week follow-up (P=.22). The control condition (n=67) did not significantly reduce all outcomes associated with mental illness stigma. Perceived autonomy was found to mediate the effect of public stigma (P=.56), and immersiveness mediated the effect of microaggression (P=.99).

Conclusions

Internet-based storytelling programs with stigma-related content and interactivity elicited the largest effects in stigma reduction, including reductions in public stigma and microaggression, although only its difference with internet-based storytelling programs with stigma-related content was not statistically significant. In other words, although interactivity could strengthen the stigma reduction effect, stigma-related content was more critical than interactivity in reducing stigma. Future stigma reduction efforts should prioritize the production of effective stigma content on their web pages, followed by considering the value of incorporating interactivity in future internet-based storytelling programs.

Trial Registration

ClinicalTrials.gov NCT05333848; https://clinicaltrials.gov/ct2/show/NCT05333848