Stephanie Knaak

Opening Minds Stigma Scale for Health Care Providers (OMS-HC): Examination of psychometric properties and responsiveness

BackgroundDiminishing stigmatization for those with mental illnesses by health care providers (HCPs) is becoming a priority for programming and policy, as well as research. In order to be successful, we must accurately measure stigmatizing attitudes and behaviours among HCPs. The Opening Minds Stigma Scale for Health Care Providers (OMS-HC) was developed to measure stigma in HCP populations. In this study we revisit the factor structure and the responsiveness of the OMS-HC in a larger, more representative sample of HCPs that are more likely to be targets for anti-stigma interventions.MethodsBaseline data were collected from HCPs (n = 1,523) during 12 different anti-stigma interventions across Canada. The majority of HCPs were women (77.4%) and were either physicians (MDs) (41.5%), nurses (17.0%), medical students (13.4%), or students in allied health programs (14.0%). Exploratory factor analysis (EFA) was conducted using complete pre-test (n = 1,305) survey data and responsiveness to change analyses was examined with pre and post matched data (n = 803). The internal consistency of the OMS-HC scale and subscales was evaluated using the Cronbach’s alpha coefficient. The scale’s sensitivity to change was examined using paired t-tests, effect sizes (Cohen’s d), and standardized response means (SRM).ResultsThe EFA favored a 3-factor structure which accounted for 45.3% of the variance using 15 of 20 items. The overall internal consistency for the 15-item scale (α = 0.79) and three subscales (α = 0.67 to 0.68) was acceptable. Subgroup analysis showed the internal consistency was satisfactory across HCP groups including physicians and nurses (α = 0.66 to 0.78). Evidence for the scale’s responsiveness to change occurred across multiple samples, including student-targeted interventions and workshops for practicing HCPs. The Social Distance subscale had the weakest level of responsiveness (SRM ≤ 0.50) whereas the more attitudinal-based items comprising the Attitude (SRM ≤ 0.91) and Disclosure and Help-seeking (SRM ≤ 0.68) subscales had stronger responsiveness.ConclusionsThe OMS-HC has shown to have acceptable internal consistency and has been successful in detecting positive changes in various anti-stigma interventions. Our results support the use of a 15-item scale, with the calculation of three sub scores for Attitude, Disclosure and Help-seeking, and Social Distance.

Opening minds in Canada: targeting change.

Objective To summarize the ongoing activities of the Opening Minds (OM) Anti-Stigma Initiative of the Mental Health Commission of Canada regarding the 4 groups targeted (youth, health care providers, media, and workplaces), highlight some of the key methodological challenges, and review lessons learned. Method The approach used by OM is rooted in community development philosophy, with clearly defined target groups, contact-based education as the central organizing element across interventions, and a strong evaluative component so that best practices can be identified, replicated, and disseminated. Contact-based education occurs when people who have experienced a mental illness share their personal story of recovery and hope. Results Results have been generally positive. Contact-based education has the capacity to reduce prejudicial attitudes and improve social acceptance of people with a mental illness across various target groups and sectors. Variations in program outcomes have contributed to our understanding of active ingredients. Conclusions Contact-based education has become a cornerstone of the OM approach to stigma reduction. A story of hope and recovery told by someone who has experienced a mental illness is powerful and engaging, and a critical ingredient in the fight against stigma. Building partnerships with existing community programs and promoting systematic evaluation using standardized approaches and instruments have contributed to our understanding of best practices in the field of anti-stigma programming. The next challenge will be to scale these up so that they may have a national impact.

Opening minds in Canada: background and rationale.

Objective To summarize the background and rationale of the approach taken by the Mental Health Commission of Canadas Opening Minds (OM) Anti-Stigma Initiative. Method The approach taken by OM incorporates a grassroots, community development philosophy, has clearly defined target groups, uses contact-based education as the central organizing element across interventions, and has a strong evaluative component, so that best practices can be identified, replicated, and disseminated. Contact-based education occurs when people who have experienced a mental illness share their personal story of recovery and hope. Results OM has acted as a catalyst to develop partnerships between community groups who are undertaking anti-stigma work and an interdisciplinary team of academic researchers in 5 universities who are evaluating the results of these programs. Conclusions Building partnerships with existing community programs and promoting systematic evaluation using standardized approaches and instruments have contributed to our understanding of best practices in the field of anti-stigma programming.

The hidden medical logic of mental health stigma

Australian & New Zealand Journal of Psychiatry, 47(7) Reducing the stigma associated with mental illness has become an area of increased effort and attention (Abbey et al., 2012; Jorm and Kitchener, 2011; Stuart et al., 2012). What remains of primary concern is how and why health care providers, who are otherwise educated, kind and compassionate helpers, are amongst the most stigmatising when dealing with mental illness (Abbey et al., 2012; Lauber et al., 2006; Stuart et al., 2012). While existing research suggests that emphasising biological aspects of mental illness does not reduce stigma and discrimination among the general public (Corrigan and Watson, 2004; Schomerus et al., 2004), we argue that the same cannot be assumed for health professionals. Health professionals are in the specific business of fixing, treating and otherwise controlling biologic disorder. As such, it is both logical and probable that health professionals apply a different set of cognitive interpretations and/or judgements to a medicalised framing of mental illness (Haslam et al., 2007) than does the general public. Informing our argument is the consideration that stigma and discrimination among health care providers can be thought of as a logical by-product (and perhaps even a result) of mind-body dualism. In contrast to what seems to work for the general public, this consideration provides the basis for the hypothesis that presenting physicians with knowledge of the physiological components of mental illness might be an effective strategy for combating stigma among this professional group. The problem of mind-body dualism dates back to Rene Descartes and refers to the philosophical split between the (non-physical) mind and the (physical) body. It is a problem that comes into play in the very way physicians think about illness and disease (Miresco and Kirmayer, 2006). When presented with a symptom or set of symptoms, for example, physicians will start by using the fundamental schematic categorisation of “Is it functional or is it organic?” If categorised as organic (i.e. in the body) it is assumed to be real, legitimate and material. From the physician’s point of view, this means it is something that can be observed, studied, treated and corrected. Arguably, this reduces stigma and discrimination. However, if categorised as functional (i.e. a problem of the mind, with no physiological correlates), the physician will consider it less real and the patient may be more likely to be stigmatised and discriminated against. Even though we ‘know’ this to be a false dichotomy, namely that mental illness (like most all illness) is inherently bio-psychosocial, this split between the material (body) and the immaterial (mind) nevertheless continues to structure our thinking. It permeates our language, explanatory models, attributions for illness, health care delivery structures, and resulting attitudes and behaviours. As linguistic philosophers Lakoff and Johnson (1980: 3) explain: “Our conceptual system ...plays a central role in defining our everyday realities .... but our conceptual model is not something we are normally aware of. In most of the little things we do everyday, we simply think and act more or less automatically along certain lines.” Anti-stigma efforts towards health care providers may be limited in their effectiveness if they ignore this basic schematic that underpins how physicians understand illness and disease. Research indicates that a more biomedically dominated conception of mental illness does not seem to reduce stigma amongst the general public – mostly because it creates in the public’s mind a perception that mental illness is less under a person’s control, that people with mental illness are more unpredictable, more potentially dangerous, more fundamentally different, and less likely to recover (Corrigan and Watson, 2004; Schomerus et al., 2004; Stuart et al., 2012). However, extending this same conclusion to health care providers may be an error. And that’s because physicians probably think about ‘the biological’ differently than the general public does. For a physician, using biological information to emphasise the ‘bio’ components of a biopsychosocial illness helps to shift the conception of that illness from something ‘merely’ functional to something organic (and therefore real and treatable). From the physician’s point of view, thinking of an illness in organic terms perhaps The hidden medical logic of mental health stigma

Mental illness-related stigma in healthcare: Barriers to access and care and evidence-based solutions

Mental illness-related stigma, including that which exists in the healthcare system and among healthcare providers, creates serious barriers to access and quality care. It is also a major concern for healthcare practitioners themselves, both as a workplace culture issue and as a barrier for help seeking. This article provides an overview of the main barriers to access and quality care created by stigmatization in healthcare, a consideration of contributing factors, and a summary of Canadian-based research into promising practices and approaches to combatting stigma in healthcare environments.

Theoretical and Practical Considerations for Combating Mental Illness Stigma in Health Care

Reducing the stigma and discrimination associated with mental illness is becoming an increasingly important focus for research, policy, programming and intervention work. While it has been well established that the healthcare system is one of the key environments in which persons with mental illnesses experience stigma and discrimination there is little published literature on how to build and deliver successful anti-stigma programs in healthcare settings, towards healthcare providers in general, or towards specific types of practitioners. Our paper intends to address this gap by providing a set of theoretical considerations for guiding the design and implementation of anti-stigma interventions in healthcare.

Stigma towards borderline personality disorder: effectiveness and generalizability of an anti-stigma program for healthcare providers using a pre-post randomized design.

BackgroundStigmatization among healthcare providers towards mental illnesses can present obstacles to effective caregiving. This may be especially the case for borderline personality disorder (BPD). Our study measured the impact of a three hour workshop on BPD and dialectical behavior therapy (DBT) on attitudes and behavioral intentions of healthcare providers towards persons with BPD as well as mental illness more generally. The intervention involved educational and social contact elements, all focused on BPD.MethodsThe study employed a pre-post design. We adopted the approach of measuring stigmatization towards persons with BPD in one half of the attendees and stigmatization towards persons with a mental illness in the other half. The stigma-assessment tool was the Opening Minds Scale for Healthcare Providers (OMS-HC). Two versions of the scale were employed – the original version and a ‘BPD-specific’ version. A 2x2 mixed model factorial analysis of variance (ANOVA) was conducted on the dependent variable, stigma score. The between-subject factor was survey type. The within-subject factor was time.ResultsThe mixed-model ANOVA produced a significant between-subject main effect for survey type, with stigma towards persons with BPD being greater than that towards persons with a mental illness more generally. A significant within-subject main effect for time was also observed, with participants showing significant improvement in stigma scores at Time 2. The main effects were subsumed by a significant interaction between time and survey type. Bonferroni post hoc tests indicated significant improvement in attitudes towards BPD and mental illness more generally, although there was a greater improvement in attitudes towards BPD.ConclusionsAlthough effectiveness cannot be conclusively demonstrated with the current research design, results are encouraging that the intervention was successful at improving healthcare provider attitudes and behavioral intentions towards persons with BPD. The results further suggest that anti stigma interventions effective at combating stigma against a specific disorder may also have positive generalizable effects towards a broader set of mental illnesses, albeit to a lessened degree.

Mental health stigma and the mind-body problem: Making the case for strategic collusion

In a recent Letter to the Editor, Thomas (2013) engages our discussion of mind-body dualism and its contribution to mental health stigma among health professionals. He insightfully points out that our suggestion to educate health professionals on the biological correlates of mental disorders to assist them in overcoming the ‘functional vs. real’ divide does not successfully break down this dualist paradigm but rather works within it. Thomas is correct: we are colluding with the dualist mindset. Although counterintuitive, we are doing so purposefully and strategically. Thomas (2013:1) suggests that a more useful way to respond to the problem of mind-body dualism would be to ‘conceptualis(e) distress in terms of interactions between biological, emotional, cognitive, behavioural and environmental factors’. We agree that a more sophisticated understanding of mental disorders can be achieved by humanising the experience of mental distress. As we argue, educating professionals about the organic correlates of mental disorders should not be taken at the expense of other ingredients already known to be successful at reducing stigma among health professionals, like contactbased education and a focus on recovery (Ungar and Knaak, 2013:2). But we still need providers to see mental disorders as real and treatable in the first place. This is where working with and leveraging the existing knowledge paradigm of health professionals is likely to be more productive than working against it. It has been our experience, for example, that among physicians in particular, anti-stigma interventions that focus on humanising mental disorders (through contact-based approaches, for example) tend to have low levels of participation unless they also include a component that teaches about mental disorders and what physicians can do to help. To this end, presenting physiological information about mental disorders may help to ensure the necessary buy-in among physicians in the first instance, while also providing the humanising component. Cultural knowledge schemas are deeply entrenched structures, resistant to change. Fields such as human factors and design thinking focus on improving health-care quality within a framework accepting of human limitations, and encourage design affordances (i.e. designing around human limitations) as a way to provide more efficient and effective pathways to the desired result (Brown and Ka –tz 2008; Vicente 2006). Working from an emic perspective also finds support in cultural psychiatry. Inasmuch as we know that different cultural groups have different ways of explaining and making sense of mental disorders, antistigma efforts are likely to be more successful if they acknowledge, understand and seek change from within one’s existing cultural schema (Haslam et al., 2007; Kleinman, 1980). Ultimately, we agree with Thomas (2013) that educating health-care providers about the biological correlates of mental disorders may not, in itself, overcome mind-body dualism. Strategically colluding with the existing knowledge paradigm of health-care providers may, however, allow us to accomplish a more immediate and practical goal – improving the quality of care of patients with mental disorders, reducing stigma and improving the experiences that patients with mental disorders have in their encounters with health-care professionals.

Impact of Skill-Based Approaches in Reducing Stigma in Primary Care Physicians: Results from a Double-Blind, Parallel-Cluster, Randomized Controlled Trial

Objective: Most interventions to reduce stigma in health professionals emphasize education and social contact–based strategies. We sought to evaluate a novel skill-based approach: the British Columbia Adult Mental Health Practice Support Program. We sought to determine the program’s impact on primary care providers’ stigma and their perceived confidence and comfort in providing care for mentally ill patients. We hypothesized that enhanced skills and increased comfort and confidence on the part of practitioners would lead to diminished social distance and stigmatization. Subsequently, we explored the program’s impact on clinical outcomes and health care costs. These outcomes are reported separately, with reference to this article. Methods: In a double-blind, cluster randomized controlled trial, 111 primary care physicians were assigned to intervention or control groups. A validated stigma assessment tool, the Opening Minds Scale for Health Care Providers (OMS-HC), was administered to both groups before and after training. Confidence and comfort were assessed using scales constructed from ad hoc items. Results: In the primary analysis, no significant differences in stigma were found. However, a subscale assessing social distance showed significant improvement in the intervention group after adjustment for a variable (practice size) that was unequally distributed in the randomization. Significant increases in confidence and comfort in managing mental illness were observed among intervention group physicians. A positive correlation was found between increased levels of confidence/comfort and improvements in overall stigma, especially in men. Conclusions: This study provides some preliminary evidence of a positive impact on health care professionals’ stigma through a skill-building approach to management of mild to moderate depression and anxiety in primary care. The intervention can be used as a primary vehicle for enhancing comfort and skills in health care providers and, ultimately, reducing an important dimension of stigma: preference for social distance.

Fighting Stigma in Canada: Opening Minds Anti-Stigma Initiative

Mental illnesses continue to gain awareness as a global health problem. Within this international context, Canada has also paid closer attention to mental illnesses and their related stigma. The Mental Health Commission of Canada was formed in 2007 as a federal government initiative to be a catalyst for improving the mental health system. Since then, the Commission has examined the many ways in which people living with mental illnesses are viewed in society and devised a series of initiatives to enhance and improve Canada’s treatment of people who live with mental illnesses. One initiative is the Opening Minds initiative, whose mandate is to change Canadians’ attitudes and behaviors toward people living with mental illnesses to ensure they are treated fairly, as full citizens with equal opportunities to contribute to society (see Stuart et al. 2014a, b).