Preventing Mental Illness and Substance Use–Related

Stigma & Discriminationand Promoting Recovery-Oriented Practices for Primary Health Care in Ontario

ObjectivesTo develop and pilot a tailored capacity-building intervention that mitigates the impact and addresses the root causes of mental health and substance use stigma and discrimination in primary care in Ontario in partnership with Community Health Centres (CHCs) that serve African, Caribbean and Latin American immigrants. Specifically to:

∞ examine and better understand stigma and discrimination in PHC

∞ identify key elements of an effective stigma reduction intervention

∞ develop a knowledge exchange process for sharing the results of this initiative with other CHCs and community-based agencies in Canada.

MethodologyA participatory action research approach using mixed methods collected information from providers, decision makers and service users about the magnitude of the problem, cultural constructs, health system structure and organizational setting at each CHC.

Action research approach

Akwatu Khenti1 , Jaime C. Sapag1, Sireesha Bobbili1, Joseph Bortolussi2, Paulos Gebreyesus3, Tamara Robert3 and Jason Altenberg4

(1) Office of Transformative Global Health, Centre for Addiction and Mental Health; (2) Central Toronto Community Health Centres; (3) Unison Health and Community Services; (4) South Riverdale Community Health Centre

Background ∞ Stigma toward people with mental illness and substance use issues is a major public health problem.

∞ Stigma encompasses stereotypes, prejudice, and discrimination, and their interaction within a particular sociocultural context.1

∞ Health care professionals, like the general population, are not immune to stigmatizing beliefs.

∞ People who seek help for mental health problems feel disrespected by and discriminated against by frontline health care workers.3

∞ There is little research about mental health–related stigma in PHCs.

∞ Stigma and discrimination are significant sources of harm for people affected by mental illness and substance use issues, specifically related to:

∞ We chose to focus on community health centres (CHCs) because they:

• are the first point of entry for individuals and families with health concerns.

• work with the most vulnerable populations who are usually affected by multiple stigmas.

• represent a key component of PHC in Canada, which places emphasis on the social determinants of health.

finding employment

finding housing

social isolation

decreased service

utilization2

Context: Why primary health care (PHC)?

Participating community health centres ∞ Central Toronto Community Health Centres

∞ South Riverdale Community Health Centre

∞ Unison Health and Community Services

InterventionBased on the literature review, environmental scans, qualitative and quantitative baseline data and symposium results, an intervention made up of five components was developed. This organizational or systems approach is multi-pronged, addressing factors at the individual, interpersonal, organizational and community levels.

Overall Findings

1 Link B, Phelan J. (2001). Conceptualizing stigma. Annual Review of Sociology, 27: 363-385

2 Pickenhagen A, Sartorius, N. (2002). Annotated bibliography of selected publications and other materials related to stigma and discrimination because of mental illness and intervention programmes fighting it. Geneva: World Psychiatric Association.

3 Mental Health Commission of Canada (2012). www.mentalhealthcommission.ca

4 Kassam A, Papish A, Modgill G, Patten S. (2012). Development and psychometric properties of a new scale to measure mental illness related stigma by health care providers: The Opening Minds Scale for Heath Care Providers (OMS-HC). BMC Psychiatry.12: 62-82.

5 Corrigan, P. W., Salzer, M., Ralph, R. O., Sangster, Y., & Keck, L. (2004). Examining the factor structure of the recovery assessment scale. Schizophrenia Bulletin, 30(4), 1035.

6 Link, B. G., Cullen, F. T., Frank, J. & Wozniak, J. F. (1987). The social rejection of former mental patients: understanding why labels matter. American Journal of Sociology 92, 1461-1500.

References

What is innovative about this project?The results will help to define training and health service initiatives that integramental and substance use issues into PHC settings in Canada, focusing on immigrant populations.

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This project was made possible through funding from the CAMH Development and Dissemination Fund

(Sep. 2010–Mar. 2012) and the Opening Minds anti-stigma anti-discrimination initiative of the Mental Health

Commission of Canada (MHCC) (Apr. 2012–July. 2015). The work of the MHCC is supported by a grant from

Health Canada.

Leadership Team Development

The plan to strengthen anti-stigma leadership at each CHC involved the cultivation of a Team of Local Champions and an advisory group. The advisory group included: individuals with lived experiences of mental health and/or substance use issues and community members residing within the CHC catchment area. Both groups provided crucial input and leadership for the various components of the intervention.

Training was created to develop the skills and comfortability levels of leaders for addressing stigma and discrimination with their peers.

Tracy Mead, staff at South Riverdale Community Health Centre and Beverly Smith, community member of Health Strength in Action Group (HSAG) were in attendance at the ‘Dealing with Difficult Conversations’ workshop on February 13, 2015.

Dale Kuehl, advanced practice clinician (CAMH), and Leslie Flores, education specialist (CAMH), developed and facilitated the workshop on ‘Dealing with Difficult Conversations’ at UnisonHCS on April 24, 2015.

Innovative Contact-Based Education

Contact-based educational workshops were developed to enhance providers’ anti-stigma and recovery-oriented competencies. The workshops incorporated adult learning principles and interactive learning methods, such as: small group activities, panel discussions and role play. A key element involved individuals with lived experiences of mental health and substance use issues, or consumer/survivors. These consumer/survivors acted as both facilitators and presenters, exchanging ideas and providing the client perspective.

Wayne Duhaney (CHC staff), Kate Freeman (CHC staff), Gordon Singer (Consumer/Survivor), and Chris Whittaker (Consumer/Survivor) participating in a panel discussion at Unison Health and Community Services in April 2014.

Chris Whittaker (third from right), Consumer/Survivor, facilitating a discussion with a small group of staff at Unison Health and Community Services in April 2014.

Raising Awareness

The project team and CHC champions, with the support of CAMH’s Creative Services Department, developed the intervention’s logo, tagline and poster in order to raise awareness among healthcare providers and the general population about stigma and discrimination toward persons with mental health and substance use problems.

Health & Community Services ENDING STIGMA

STARTS WITH YOU

Stigma = negative attitudes + negative behaviours Do you play a part?

This initiative is funded by CAMH, 2010-2011 Development and Dissemination Grant (Primary Health Care).

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people with mental health and substance use issues face

stigma

Photo used for illustrative purposes only and any person depicted in content is a model.

Recovery-Based Arts

Staff and clients attended workshops to collaboratively explore stigma, discrimination and recovery through art. The main purpose was to breakdown the misconceptions about consumer/survivors in a creative manner. Contact-based education, recovery-oriented perspectives and art were combined to address these stereotypes. Contact-based education allowed PHC providers to gain a better understanding of the role they play in stigma, discrimination, and recovery from the perspective of consumer/survivors. A focus on recovery allowed consumer/survivors to actively take on the challenges of stigma and discrimination throughout the workshop series to create a sense of purpose and identity beyond their symptoms and illness. Since art has the ability to encourage the ‘unlearning’ of socially ingrained stereotypes, it was used as a vehicle to bring staff and consumer/survivors together to discuss prejudice and discrimination in a safe environment.

Analysis of Internal Policies and Procedures

Policies and procedures can manifest structural stigma and discrimination unintentionally. This can ultimately contribute to the disparity in care that consumer/survivors face. Since a policy analysis tool for identifying stigmatizing content did not exist, one was developed based on a number of existing frameworks.

Project staff and CHC champions examined policy areas for strengths, gaps and opportunities for enhancing service delivery for consumer/survivors. The analysis considered the mix of policies and procedures in place to address contextual factors at a systems level; minimizing negative effects and implications while promoting recovery-based procedures. The analysis resulted in the development of concrete and context specific recommendations that address key consumer/survivor concerns.

Lorraine Barnaby, health promoter, Central Toronto Community Health Centre, along with CTCHC staff and consumer-survivor participants creating art in April 2015.

The group artwork of the positive counterpart of stigma, created in the workshop at Unison Health and Community Services at the Keele-Rogers site.

Salha Al-Shuwehdy, Wanda Georgis and Gurpreet Karir pictured in front of the group artwork at the South Riverdale Community Health Centre Final Art Show,