camh webinar mark van der maas - eenet · 2019-12-12 · mark van der maas post-doctoral fellow,...

A Cluster RCT Study Exploring Stigmatization and Recovery-Based

Perspectives Regarding Mental Illness and Substance Use Problems

among Community Health Centre Staff across Toronto

Emily Lentinello

Project Coordinator / Special Advisor

Mark van der Maas

Post-Doctoral Fellow, CAMH

CAMH Webinar September 19, 2017

+ Learning Objectives

1. To provide an overview of a three year anti-stigma

project

2. To summarize a five-pronged intervention for

reducing stigmatizing attitudes and behaviours

among Community Health Centre (CHC) staff

toward people with mental health and substance

use problems

3. To learn the results of how CHCs that received the

intervention compare with those that did not and

what the next steps should be.

+ Defining the Problem

+ Stigma & Discrimination in MH&A

• Stigma & discrimination towards MH&A is

widespread and a major public health concern

• Health professionals are no less susceptible to

stigmatizing beliefs and behaviours than members

of the general public (Schulze, 2007; Corrigan, 2004)

• Stigma and discrimination prevents clients/patients

and families to seek mental health care (WHO)

• Clients/patients often report that MH&A stigma is

more difficult to bear than the actual

illness/condition (Angermeyer, et al, 2003)

+

Why Primary Health

Care?

+ Why Focus on Health Care

Professionals?

• Primary care settings are often the first point of

contact for people with mental health and/or

substance use problems

• Primary care settings, such as community health

centres, offer a wide range of services and tend to

work with people that are most marginalized and

vulnerable

• CHCs provide services to people who do not have

OHIP or other means of payment

• Working within an interdisciplinary and non-

discriminatory framework is key to CHC mandates

and core values

+ Why Focus on Health Care

Professionals?

There is a knowledge gap

• Scarcity of studies examining mental health related stigma

in primary health care (PHC)

• Even fewer studies focus on implementing interventions

aimed at reducing stigma among health care professionals

working in PHC

+ The Pilot Project

• Funded by CAMH’s Development and

Dissemination Grant in Primary Health

Care and MHCC Opening Minds

• In collaboration with three CHCs (Unison,

Central Toronto, and South Riverdale)

• Developed a comprehensive,

organizational-level intervention based on:

a) Participatory action research

b) Feedback from a knowledge-translation

symposium

c) Development of tailored implementation plans

for each CHC

+

• Initial results were positive,

BUT • There was no comprehensive

evaluation conducted to

determine the effectiveness of

the intervention in addressing

stigmatizing attitudes and

discriminatory behaviours and

the impact on individuals with

MHSUP.

The Pilot Project

+ The Anti-Stigma Intervention

+ What is the CIHR Anti-Stigma

Intervention?

Purpose:

To determine the effectiveness of a

(RCT) comprehensive recovery-

oriented anti-stigma intervention in

reducing stigmatizing attitudes and

behaviours among PHC providers

towards individuals with MHSUP in

the Canadian context, using

Community Health Centres (CHCs)

as a point of intervention.

+ Participating CHCs Using an RCT model, three CHCs in the GTA were randomly

selected to be experimental (intervention sites).

Three CHCs in the GTA were selected to be controls.

+

Specific hypotheses:

1. Participation in experimental group will

result in a significant decrease in

stigmatizing and discriminatory attitudes

among PHC providers towards clients

with MHSUP compared to control group.

2. Participation in the experimental group

will result in a significant decrease of

clients’ experiences of MHSUP stigma

conveyed by CHC staff compared with

control group.

What is the CIHR Anti-Stigma

Intervention?

+ What is the Intervention?

Team of Champions

Innovative Contact-

Based Trainings

Raising Awareness

Analysis of Internal

Policies and Procedures

Recovery-based Arts

+ Component 1: Team of Champions

• Involves the identification and formation of

Team of Local Champions (staff at CHCs)

• Champions provide input and leadership

in the project and assist with logistical

support

+

Innovative Contact-

Based Trainings

Raising Awareness

Analysis of Internal Policies and Procedures

Recovery-based Arts

Team of Champions

+

• Half-day educational

workshops for CHC

providers designed to

increase knowledge and

share information on anti-

stigma and discrimination

for people living with

MHSUP

• Facilitated by experts in

the field, along with

consumer-survivors

Component 2:

Innovative Contact-Based Training

+ Training session data

• According to the final survey, approx.

76% of respondents attended at least one

training session and approx. 33%

attended all four.

• Staff generally reported high satisfaction

with the training sessions (4.1/5 for

overall of training 4)

• Staff tended to appreciate the clients with

lived experience the most (4.3/5)

• Staff rated that the sessions would

change their practices the lowest (3.7/5)

+

Raising Awareness



Recovery-based Arts

Team of Champions

Innovative Contact-Based

Trainings

+ Component 3: Raising Awareness

• Involved the use of various forms of

media to increase awareness about

stigma and discrimination as well

as to showcase recovery

• Posters were developed with the

direct guidance and participation of

CHC staff and clients

• In collaboration with the Team of

Champions from the intervention

sites, a brand and logo was

developed and used for materials

such as pens and buttons.

+



Recovery-based Arts

Team of Champions

Innovative Contact-

Based Trainings

Raising Awareness

+ Component 4:

Analysis of Internal Policies & Procedures

• Evaluation of CHC policies and procedures using an

anti-stigma approach to identify strengths and areas

for improvements in service delivery

• Team of Local Champions identified relevant policies

• Used a collection of validated policy assessment tools

to determine whether policies and procedures can be

improved to better serve clients living with MHSUP

• CHCs were provided with recommendations and

implemented a select number

+

Recovery-based

Arts

Team of Champions

Innovative Contact-Based

Trainings

Raising Awareness



+ Component 5: Recovery-based Arts

• The Team of Champions helped identify a staff

facilitator and an artist to lead the art program

• Over 10 weekly sessions, clients with MHSUP (10)

and CHC staff (3-4) participated

• CHCs showcased the art during an event they

organized. Audience members were made up of

staff, other clients, Board members, and the

community.

• This was followed by participating in a focus group

to learn more about the impact of the program and

the experience of staff and clients working

together.

+ Art Program Focus Group Overview

• Overall, participants enjoyed the program and

found the discussions and artistic creativity

engaging

• Participants used a variety of art media including

paint, encaustic wax, and clay

• Some client participants expressed concern that

staff were there as they did not realize staff

participants were part of the program. Clients

expressed feeling observed and disconnected at

times

• CHC staff that attended the art event found it

informative and appreciated seeing the art

+ Evaluation

+ Data Collection - Staff

• All CHC staff completed a survey at 4 different

time points

• Three of the four were completed online while the

first was completed with paper/pencil.

• Interviews were conducted with a random sample

of 18 staff at baseline

• Staff completed evaluations at the end of each

training session

• Staff that participated in the Art Program were

engaged in a focus group following the program

+ Quantitative Tools (Staff)

1. Opening Minds for Health Care Providers (Opening Minds, MHCC)

2. Mental Illness: Clinician's Attitudes Scale (MICA)

3. Bogardus Social Distance Scale (Schizophrenia and Heroin

Dependence)

4. Recovery Assessment Scale (Corrigan)

5. Recovery Self-Assessment (RSA) – RSA-R – Provider Version (O’Connell et al, 2007)

6. Marlowe-Crowne Social Desirability Scale

7. Personal or Close Experiences with Mental Illness and/or

Addictions

8. Socio-Demographic Information

9. Work roles and practices

+ Data Collection - Clients

• Clients that were part of the project had to identify

as having a mental health and/or substance use

problem within the 12 months prior to the study

• CHC clients completed a survey at 4 different time

points

• All surveys were completed with the Research

Coordinator

• Interviews were conducted with a random sample

of clients at baseline and follow-up (25 in total)

• Clients that participated in the Art Program were

engaged in a focus group following the program

+ Quantitative Tools (Clients)

1. Revised Perceived Devaluation Discrimination Scale (Link, 1987)

2. Revised Internalized Stigma of Mental Illness Scale (Ritsher et al, 2003)

3. Stigma Module from the Stats Canada Survey (Adapted

Questions) (Stats Canada, 2008)

4. Recovery Self-Assessment – RSA-R Person in Recovery Version (O’Connell et al, 2007)

5. Marlowe-Crowne Social Desirability Scale

6. Personal or Close Experiences with Mental Illness and/or

Addictions

7. Socio-Demographic Information

8. Types of services sought

+ Overall Results

• Total number of staff that completed the

surveys (all CHCs): 392

• Total number of clients that completed the

surveys (all CHCs): 89

+ Quantitative Findings

• Modelling over time to examine the

effectiveness of the intervention

• Linear mixed effects regression models

• Results show that intervention CHCs did

significantly better over time for several

scales

• OMS-HC

• MICA

• Bogardus: Schizophrenia

+ Opening Minds Survey for Health

Care Providers

• Explores the attitudes and intentions

towards mental health clients

• Higher scores indicate more

stigmatizing attitudes

• Intervention sites

• First survey: 45.1, Last survey: 43.1

• Control sites


+ Intervention over time

(example)

39

39.5

40

40.5

41

41.5

42

42.5

43

43.5

1 2 3 4

Wave

OM

S-H

C

OMS-HC scores over time Control Intervention

+ Mental Illness: Clinician’s Attitudes

Scale (MICA) • Scale that measures respondents’

attitudes towards those with mental

illness.

• Higher scores indicate more

stigmatizing attitudes



• Control sites


+ Modified Borgadus Social

Distance Scale • Asks if respondent would feel

uncomfortable in a series of social

situations with a person with schizophrenia

or heroin dependence

• Four possible responses ranging from

“definitely not (1)” to definitely yes (4)”

• Higher scores indicate greater desired

social distance.

+ Modified Borgadus Social Distance

Scale

• Heroin Dependence



• Control sites


• Schizophrenia



• Control sites


+ Recovery Assessment Scale‐(Mental

Illness and Addictions)

• Measures the extent to which

respondents feel those with mental health

or addiction problems are able to recover

• Respondents are asked to agree or

disagree with a series of statements

related to recovery

• Higher score indicate less positive

attitudes about recovery

+ Recovery Assessment Scale

Recovery Assessment Scale ‐ Mental Illness



• Control sites


Recovery Assessment Scale ‐ Addictions



• Control sites


+ Recovery Self‐Assessment (RSA)

RSA‐R ‐ Provider Version

• Designed to determine the extent to which a program implements recovery-oriented practices

• Higher scores indicate better implementation of recovery-oriented practices



• Control sites


+ Client results

• Linear mixed effects regression

models (similar to staff)

• Significant improvement for

Perceived Devaluation and

Discrimination Scale at intervention

sites

• Other scales do not show significant

effects

+ Client Results

• Perceived Devaluation and

Discrimination Scale

• Higher scores indicate feelings that staff

are accepting of those with MHSUP

• Intervention- First: 17.4, Last:18.2

• Control- First: 23.1, Last:18.5

• Revised Internalized Stigma of Mental

Illness Scale

• Higher scores indicate more negative

interactions with staff

• Intervention- First: 7.3, Last: 7.4

• Control- First: 9.1, Last: 8.6

+ Client improvement example

15

16

17

18

19

20

21

22

23

1 2 3 4

Wave

Pe

rce

ive

ived

De

valu

atio

n a

nd

d

iscr

imin

atio

n

Devaluation over time Intervention Control

+ Client Results (con’d)

• Statistics Canada Stigma Module

• Higher scores indicate being at the

CHC has led to more negative

consequences in their lives



• The Recovery Self-Assessment:

Person in Recovery

• Higher scores indicate better use of

recovery oriented practices at the CHC



+

• Both groups recognize that stigma exists

within PHC

• Both recognize that stigma has a negative

impact

• Both groups recognize that education and

training is a key component in breaking

the stigma

• Experience of stigma is not the same for

everyone (culture, gender, MI vs SUP

differences)

Qualitative Themes

+ Selection of staff recommendations to

reduce stigma

When providers discussed how stigma

might be addressed, several

recommendations were reported:

1. Highlight the importance of collaboration between

healthcare providers and teams.

2. Incorporate client perspective when developing

programs and services for MHSUP.

3. Incorporate cultural perspectives when developing

programs and services, especially when

compounded stigma may be a factor.

4. Include programs and services with peer support

workers.

+ Selection of staff recommendations to

reduce stigma (con’t.)

5. Provide staff with opportunities to discuss biases

in a non-judgemental space and support and

offer safe spaces for staff to discuss challenging

clients and situations

6. Provide contact based educational trainings and

workshops on MHSUP and stigma

7. Provide training on how to de-escalate situations,

using a practical and hands on approach

8. Include stigma training as part of new staff

orientation.

+ Selection of client recommendations to

reduce stigma When participants discussed how stigma might be

addressed, several recommendations were reported:

1. Incorporate cultural perspectives when developing

programs and services for MHSUP, especially

when compounded stigma may be a factor.

2. When providers are working with immigrants and

refugees, explore the client’s knowledge about

MHSUP to determine whether they are aware of

MHSUP and if stigma is a cause of non-

disclosure.

3. Awareness campaigns should highlight individual

experiences and challenge MHSUP stereotypes.

+ Selection of client recommendations to

reduce stigma (con’t.)

1. Encourage collaboration between healthcare

providers and clients living with MHSUP.

2. Offer workshops and groups for clients living with

MHSUP and their families.

3. Support a peer support model, and encourage

clients living with MHSUP to develop workshops

and groups for clients and for healthcare

providers.

4. Support harm reduction frameworks, especially for

marginalized groups like pregnant/parenting

woman who use substances.

+ Challenges 1. Workload of CHCs.

2. Confidentiality and sensitivity of stigma survey.

3. Difficult to determine which component was most

successful.

4. Stigma may have been reduced at the individual level,

but time will tell if this change is felt across the CHC at

an organization level.

5. Contact-based interventions work well in the short term

but studies show their effectiveness declines in the

medium/long-term. Booster sessions may prove

important.

6. Most client surveys conducted during the day so may

have missed people that are unable to take time from

work

+ Conclusion So…does the intervention work? Do all the components reduce

stigma among primary providers towards people with MHSUP?

• Using the staff data, this project demonstrates significant

improvements among staff attitudes and behaviours towards

people with MHSUP

• Staff in the intervention group certainly show improved rates

compared with the control group

• Difficult to say which component(s) had the greatest impact

• Client data also difficult as the numbers are not particularly

strong

• One tool does show improvement over project period

Even though we seem to be talking about stigma all the time given

the population that we serve, this project helped us to really look

within ourselves, within our systems and policies, and address the

barriers that exist. When an initiative involves the entire agency, it

helps everybody to be on the same page. – CHC Director

For all questions pertaining to this project or other work in the

Office of Transformative Global Health, contact:

Emily Lentinello

Project Coordinator / Special Advisor, OTGH

416-535-8501 x34323

[email protected]

QUESTIONS?

camh webinar mark van der maas - eenet · 2019-12-12 · mark van der maas post-doctoral fellow,...

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