camh webinar mark van der maas - eenet · 2019-12-12 · mark van der maas post-doctoral fellow,...
TRANSCRIPT
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
Analysis of Internal
Policies and Procedures
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.
+
Analysis of Internal
Policies and Procedures
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
Analysis of Internal
Policies and Procedures
+ 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
• First survey: 42.1, Last survey: 42.0
+ 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
• Intervention sites
• First survey: 37.0, Last survey: 34.8
• Control sites
• First survey: 34.0, Last survey: 33.2
+ 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
• Intervention sites
• First survey: 14.9, Last survey: 14.1
• Control sites
• First survey: 14.1, Last survey: 13.6
• Schizophrenia
• Intervention sites
• First survey: 12.2, Last survey: 11.3
• Control sites
• First survey: 11.3, Last survey: 11.1
+ 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
• Intervention sites
• First survey: 50.9, Last survey: 47.7
• Control sites
• First survey: 49.4, Last survey: 45.7
Recovery Assessment Scale ‐ Addictions
• Intervention sites
• First survey: 55.1, Last survey: 49.8
• Control sites
• First survey: 52.6, Last survey: 48.8
+ 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
• Intervention sites
• First survey: 131.6, Last survey: 132.3
• Control sites
• First survey: 127.0, Last survey: 131.5
+ 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
• Intervention- First: 10.8, Last: 6.3
• Control- First: 22.6, Last: 16.4
• The Recovery Self-Assessment:
Person in Recovery
• Higher scores indicate better use of
recovery oriented practices at the CHC
• Intervention- First: 130.5, Last: 122.3
• Control- First: 119.4, Last: 121.5
+
• 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
QUESTIONS?