INDIGO-Primary:

Leads: Dr Mirja Koschorke, Prof Brandon Kohrt

Background: Stigma among primary care providers is a barrier to effective delivery of mental health services in primary care. There is a lack of evidence on effective interventions to reduce stigma in healthcare settings and specifically in primary care. In addition, few studies have compared the attitudes of primary care providers and experiences of people with mental illness across diverse primary care settings. Such research is necessary to characterise stigma, design effective interventions and contribute thereby to reducing the treatment gap for mental disorders.

Aims: The INDIGO PRIMARY NETWORK study aimed to provide foundational information necessary for the development, implementation and evaluation of  interventions to improve knowledge, attitudes and behaviour of primary care staff towards people with mental illness in diverse primary care settings. The results of the study were later applied in the context of the larger INDIGO PRIMARY PARTNERSHIP study carried out in some of the same sites to inform the development of interventions, procedures for adapting these to suit different contexts and the implementation of a multisite feasibility study of the interventions.

Methods:

Methods comprised (i) a systematic review of the existing evidence on effective interventions to achieve health care provider behaviour change, with a focus on what is effective in LAMIC and

(ii) situational analyses to understand the current clinical processes at Primary Health Care centres in the participating sites, as well as potential barriers to optimal clinical practices.

The systematic review compiled evidence on interventions to reduce mental health-related stigma among medical and nursing students in low- and middle-income countries. Primary outcomes were stigmatising attitudes and discriminatory behaviours. For the situational analyses, qualitative research was conducted on mental illness stigma in primary care settings in four low- and middle-Income countries (India, Nepal, Lebanon, Tunisia) and three high-income countries (Czech Republic, Hungary, Italy). Qualitative data included 133 total participants: 53 primary care providers and 15 primary care facility managers; and 44 people with mental illness and 21 caregivers of people with mental illness. Data were analysed using framework analysis.

Results. In the systematic review, a total of 9 studies from six different countries (Brazil, China, Malaysia, Nigeria, Somaliland, and Turkey) were included. Studies with contact interventions (either face-to-face or video) seemed to be effective. However, there was a clear lack of studies focusing on discriminatory behaviours or on training of specific skills. Methods for cultural adaptation of interventions were rarely documented. The results of situational analyses revealed that primary care providers endorsed some willingness to help persons with mental illness but reported not having appropriate training and supervision to deliver mental health care. People with mental illness did not report high levels of discrimination from primary care providers, but they reported internalized stigma and discrimination from family and community members. Providers and people with mental illness reported lack of regular mental health medication supply and lack of infrastructure for confidential consultations.  

Conclusions. The results of the foundational INDIGO PRIMARY NETWORK study showed in a systematic review an increase in studies on anti-stigma interventions in low- and middle-income countries, and that some of these studies used contact interventions and showed positive effects. The results of situational analyses indicated that primary care providers’ willingness to interact with people with mental illness and receive more training presented an opportunity to address the range of stigmatizing beliefs and stereotypes they endorse. Results further suggested that interventions aimed at increasing primary care providers’ knowledge and skills to treat mental illness should address these stigmatizing beliefs, as well as explore how providers can play a role in reducing internalized stigma and discrimination from families and communities. The INDIGO PRIMARY NETWORK study thereby provided important foundational information that directly influenced the design and implementation of the larger INDIGO PRIMARY PARTNERSHIP Study carried out in some of the same sites and may serve the development of future much needed studies on anti-stigma interventions in diverse primary care settings.

Publications:

• Koschorke M, Oexle N, Ouali U, Cherian AV, Deepika V, Mendon GB, et al. (2021) Perspectives of healthcare providers, service users, and family members about mental illness stigma in primary care settings: A multi-site qualitative study of seven countries in Africa, Asia, and Europe. PLoS ONE 16(10): e0258729. https://doi.org/10.1371/journal.pone.0258729
• Heim, E., C. Henderson, B. A. Kohrt, M. Koschorke, M. Milenova, and G. Thornicroft. “Reducing Mental Health-Related Stigma among Medical and Nursing Students in Low- and Middle-Income Countries: A Systematic Review.” Epidemiology and Psychiatric Sciences 29 (2020): e28. https://doi.org/10.1017/S2045796019000167

Abi Hana, R., Arnous, M., Heim, E. et al. Mental health stigma at primary health care centres in Lebanon: qualitative study. Int J Ment Health Syst 16, 23 (2022). https://doi.org/10.1186/s13033-022-00533-y