Petra C. Gronholm

Interventions to reduce discrimination and stigma: the state of the art

BackgroundThere is a rich literature on the nature of mental health-related stigma and the processes by which it severely affects the life chances of people with mental health problems. However, applying this knowledge to deliver and evaluate interventions to reduce discrimination and stigma in a lasting way is a complex and long-term challenge.MethodsWe conducted a narrative synthesis of systematic reviews published since 2012, and supplemented this with papers published subsequently as examples of more recent work.ResultsThere is evidence for small to moderate positive impacts of both mass media campaigns and interventions for target groups in terms of stigma-related knowledge, attitudes, and intended behaviour in terms of desire for contact. However, the limited evidence from longer follow-up times suggests that it is not clear whether short-term contact interventions have a lasting impact.ConclusionsThe risk that short-term interventions may only have a short-term impact suggests a need to study longer term interventions and to use interim process and outcome data to improve interventions along the way. There is scope for more thorough application of intergroup contact theory whenever contact is used and of evidence-based teaching and assessment methods when skills training is used for target groups.

Mental health service use by young people: the role of caregiver characteristics.

Aims Many children and adolescents experiencing mental health problems do not receive appropriate care. Strategies to encourage appropriate access to services might be improved by a more detailed understanding of service use determinants within this group. In view of caregivers’ key role in young people’s pathways to care, this study aimed to advance understanding of caregiver-related characteristics that influence service use among young people. Methods We interviewed 407 primary caregivers of young people aged 9-18 years, recruited from a Greater London (United Kingdom) community sample. Caregivers reported on young people’s service use in health care sector and/or education settings, and caregivers’ intended stigmatising behaviours, help-seeking attitudes, and personal service use. Logistic regression analyses examined the relationship between these caregiver characteristics and young people’s service use, controlling for young people’s clinical and socio-demographic factors. Results Caregivers’ intended stigmatising behaviours in particular exerted a strong influence on young people’s service use within each service setting. The impact of this characteristic interacted with caregivers’ service use in influencing young people’s service use across health care and education settings and health care settings specifically. For young people’s service use within education settings, caregivers’ intended stigmatising behaviours score had a main effect. Conclusions This study highlights the key role caregivers’ attitudes and experiences hold in young people’s service use. The findings indicate that strategies aiming to bridge the gap between young people’s service needs and utilisation might be improved by targeting stigma amongst caregivers.

Strategy modulates spatial perspective-taking: evidence for dissociable disembodied and embodied routes.

Previous research provides evidence for a dissociable embodied route to spatial perspective-taking that is under strategic control. The present experiment investigated further the influence of strategy on spatial perspective-taking by assessing whether participants may also elect to employ a separable “disembodied” route loading on inhibitory control mechanisms. Participants (N = 92) undertook both the “own body transformation” (OBT) perspective-taking task, requiring speeded spatial judgments made from the perspective of an observed figure, and a control task measuring ability to inhibit spatially compatible responses in the absence of a figure. Perspective-taking performance was found to be related to performance on the response inhibition control task, in that participants who tended to take longer to adopt a new perspective also tended to show a greater elevation in response times when inhibiting spatially compatible responses. This relationship was restricted to those participants reporting that they adopted the perspective of another by reversing left and right whenever confronted with a front-view figure; it was absent in those participants who reported perspective-taking by mentally transforming their spatial orientation to align with that of the figure. Combined with previously published results, these findings complete a double dissociation between embodied and disembodied routes to spatial perspective-taking, implying that spatial perspective-taking is subject to modulation by strategy, and suggesting that embodied routes to perspective-taking may place minimal demands on domain general executive functions.

Cross-Validation of Two Commonly Used Self-Stigma Measures, Taiwan Versions of the Internalized Stigma Mental Illness Scale and Self-Stigma Scale – Short, for People With Mental Illness

Self-stigma instruments investigate how people with mental illness internalize public stigma. However, information is limited for the psychometric properties of their scores, especially cross-validating scores from different instruments. Thus, we used confirmatory factor analyses (CFAs) and item-response theory (IRT) models to examine the Internalized Stigma Mental Illness (ISMI) scale and the Self-Stigma Scale–Short (SSS-S). Participants with mental illness (n = 347) completed both instruments. The CFAs that simultaneously accounted for both the instrument (ISMI and SSS-S) and the trait (Affect, Cognitive, and Behavior concepts) effects outperformed those that accounted only for the instrument effect or only the trait effect. All item scores fit the IRT model and were fit with ordered, progressing hierarchies in their step difficulties. We conclude that both instruments are feasible for measuring the self-stigma and that future research can combine the items of both.

Conditional Disclosure on Pathways to Care: Coping Preferences of Young People at Risk of Psychosis.

The interrelationship between stigma and help-seeking is under-researched among children and adolescents. This study explored stigma in relation to pathways to care among young people putatively in an early stage of increased risk of developing psychotic disorders. “Pathways to care” was defined as help-seeking and support from informal and formal resources, and increased risk was determined through the presence of persistent psychotic-like experiences and internalizing/externalizing psychopathology. Twenty-nine qualitative interviews were analyzed using thematic analysis. We defined the superordinate theme in these data as “conditional disclosure,” a concept reflecting the rules and prerequisites that influenced how/whether participants sought help. Through parallels between these findings and established stigma theory, we examined how these conditions could be interpreted as influenced by stigma. Our findings demonstrate the influence of stigma on young people’s perceptions of a range of pre-clinical symptoms, and on how they seek support for these symptoms.

Thailand’s national universal developmental screening programme for young children: action research for improved follow-up

Introduction In low-income and middle-income countries, it is estimated that one in every three preschool-age children are failing to meet cognitive or socioemotional developmental milestones. Thailand has implemented a universal national developmental screening programme (DSPM) for young children to enable detection of developmental disorders and early intervention that can improve child health outcomes. DSPM implementation is being hampered by low attendance at follow-up appointments when children fail the initial screening. Methods Action research, using qualitative methods was conducted with 19 caregivers, 5 health workers and 1 chief at two Health Promotion Hospitals to explore the factors affecting attendance at follow-up appointments. Transcripts and notes were analysed using descriptive content analysis. Findings were then discussed with 48 health workers, managers, researchers and policymakers. Results The high workload of health workers during busy vaccination clinics, and inadequate materials prevented clear communication with caregivers about the screening, how to stimulate child development and the screening result. Caregivers, particularly grandparents, had a lack of understanding about how to stimulate child development, and did not fully understand failed screening results. Caregivers felt blamed for not stimulating their child’s development, and were either worried that their child was severely disabled, or they did not believe the screening result and therefore questioned its usefulness. This led to a lack of attendance at follow-up appointments. Conclusion Task-sharing, mobile health (mhealth), community outreach and targeted interventions for grandparent caregivers might increase awareness about child development and screening, and allow health workers more time to communicate effectively. Sharing best practices, communication training and mentoring of DSPM workers coupled with mhealth job aids could also improve caregiver attendance at follow-up. Engagement of caregivers in understanding the barriers to attendance at follow-up and engagement of stakeholders in the design and implementation of interventions is important to ensure their effectiveness.

Care coordinator views and experiences of physical health monitoring in clients with severe mental illness: A qualitative study

Background: Excess mortality among people with severe mental illness (SMI) is largely attributed to co-morbid physical illness. Improving the physical health of this population is critically important; however, physical health monitoring among people with SMI is often inadequate. Aims: This study aimed to facilitate an enhanced understanding of barriers to successfully attend to clients’ physical health in mental health settings, through exploring care coordinators’ views and experiences regarding their ability to monitor physical health in clients with SMI (specifically, psychosis). Methods: Semi-structured interviews were conducted with seven care coordinators from a South East London (UK) community mental health team. Data were analysed using thematic analysis principles. Results: Three themes were identified in these data, capturing (1) how care coordinators viewed the professional roles of other clinical staff and themselves, (2) views on barriers to the provision of physical healthcare and (3) factors that motivated care coordinators to attend to clients’ physical health. Conclusion: Our findings can inform efforts to implement physical healthcare interventions within mental health settings. Such insights are timely, as academic literature and guidelines regarding clinical practice increasingly promote the value of integrated provision of mental and physical healthcare.

33.4 UNDER WHAT CONDITIONS DO YOUNG PEOPLE DISCLOSE THEIR DIFFICULTIES? SUBJECTIVE EXPERIENCES OF YOUNG PEOPLE AT RISK OF DEVELOPING PSYCHIATRIC DISORDER

Abstract Background Stigma and discrimination are proposed as critical factors contributing to the underuse of mental health services amongst young people, however these influences remain understudied. Existing research on stigma experienced by young people has focused on individuals in contact with mental health services or with a psychiatric diagnosis. Using a community sample, this study investigates subjective accounts of stigma during the early stages of mental health difficulties with regards to how disclosure and coping are considered, and how help-seeking is approached. Methods In-depth semi-structured individual interviews were conducted with young people from a Greater London, UK, community cohort. Purposive sampling criteria were used to recruit participants who reported early psychopathology of a persisting nature (emotional and/or behavioural difficulties at a clinical level, and psychotic-like symptoms), thus representing young people at-risk of developing psychiatric disorder. 29 young people aged 12-18 years took part in the study. Thematic analysis was used to analyse the interview data. Results In-depth semi-structured individual interviews were conducted with young people from a Greater London, UK, community cohort. Purposive sampling criteria were used to recruit participants who reported early psychopathology of a persisting nature (emotional and/or behavioural difficulties at a clinical level, and psychotic-like symptoms), thus representing young people at-risk of developing psychiatric disorder. 29 young people aged 12-18 years took part in the study. Thematic analysis was used to analyse the interview data. Discussion “Conditional disclosure” is central to how young people cope with their difficulties. Often stigma-related concerns in particular contributed to restricted disclosure, in this way delaying young people’s initial help-seeking when difficulties emerge.

33.3 LEVELS OF AND IMPLICATIONS FOR PERSONAL STIGMA AND MENTAL HEALTH LITERACY IN RELATION TO PSYCHOSIS AMONG YOUNG PEOPLE WITH AND WITHOUT RISK OF DEVELOPING PSYCHOTIC DISORDER

Abstract Background Much anti-stigma work suggests that reducing stigma and improving mental health literacy could also improve access to care and support for people with psychotic disorders. This is important given that increasing help-seeking, especially during the early stages of psychosis could reduce the substantial delays to care experienced by people with psychotic disorders. Little is known about levels of personal stigma and mental health literacy among young people at-risk of psychotic disorders, whether there are differences between young people with and without elevated risk for psychosis and how this is associated with actual help-seeking for individuals at-risk of developing psychotic disorders. Methods We interviewed participants from two existing, ongoing prospective cohorts in the UK and in Brazil. Participants were initially recruited from primary schools. Both samples represent enriched community cohorts (including a greater than average proportion of young people at risk of developing psychotic disorders) in Greater London (n=407) and a similar cohort of young people in Brazil (n=1,500). Participants were presented a vignette depicting a young person with early psychosis symptoms and asked about: recognition of the disorder; intended help-seeking; beliefs about interventions and prevention, stigmatising attitudes and whether they knew someone with a similar problem. We also collected detailed clinical data on psychiatric symptoms (via SDQ [Strengths and Difficulties Questionnaire] in the UK and DAWBA [Development and Well-Being Assessment] in Brazil), presence of psychotic-like experiences, and use of mental health services and personal experiences of seeking support for a mental disorder. Results Findings on the relationship between personal stigma and mental health literacy in relation to psychotic disorders, intended help-seeking and actual mental health service use, will be presented among young people with and without risk of developing psychotic disorders in the UK and Brazil. Discussion Reducing personal stigma and improving mental health literacy among young people at risk of psychosis who do not yet use clinical services could be important for future help-seeking. Future research should investigate the impact of anti-stigma interventions among young people with and without risk of developing psychotic disorders and how this facilitates help-seeking and support for this vulnerable group.

Mental Health Related Stigma as a ‘Wicked Problem’: The Need to Address Stigma and Consider the Consequences

Recent reviews on the evidence base for mental health related stigma reduction show that under certain conditions interpersonal contact is effective in promoting more positive attitudes, reduced desire for social distance, and increased stigma related knowledge (knowledge which disconfirms beliefs based on stereotypes). Short-term interventions may have effects that are attenuated over time; longer term programmes may support sustained improvements, but research following up long-term interventions is scarce. However, the effectiveness of these interventions should not obscure the nature of stigma as a social problem. In this article we describe stigma as a ‘wicked problem’ to highlight some implications for intervening against stigma and evaluating these efforts. These include the risks of unintended consequences and the need to continually reformulate the concept of stigma, to ensure that tackling stigma at the structural, interpersonal, and intrapersonal levels become part of the core business of stakeholder organisations. We compare the main targets of anti-stigma programmes with what is known about the sources of stigma and discrimination and their impacts to identify targets for future intervention. In some cases, interventions have been directed at the interpersonal level when structural level intervention is also needed; in others, systematic reviews have not so far identified any interventions.