Question & problem
People with mental illness have higher disability and mortality rates globally as a result of access gaps between available mental health providers and potential users (WHO, 2013). Between 76% and 85% of people with severe mental illness in low- and middle-income countries (LMICs) do not have access to mental health care services (WHO, 2013). Stigma is a major barrier to mental health service delivery and can impact care-seeking behaviours. Stigma refers to a set of beliefs and attitudes about people with mental disorders which can create an environment of discrimination on a public, personal and institutional level (e.g. healthcare systems). The fear of discrimination can delay access to care as well as influence poor adherence to treatment and follow-up. This brief highlights effective strategies for eliminating stigma as a barrier to accessing health services for people with mental illness in LMICs.
Quote
Recommendations
Key recommendation
Action
- Integrate mental health services into primary health care to reduce the treatment gap for people with mental disorders. Initiatives like the World Health Organization’s Mental Health Gap Action Programme has been used in many settings to implement these initiatives.
- Train general health care staff on mental health to reduce stigma and enhance access to mental health.
- Inclusion of mental health education in medical and nursing institutions’ curricula to improve knowledge and attitudes on mental health
Key recommendation
Action
- Prioritise relatives, neighbours and close social networks of people with mental illness in the design and implementation of anti-stigma reduction programs.
- Train health care workers, disabled peoples organizations (DPOs) and community leaders in promoting awareness of mental health stigma and treatment among people with mental disorders and family members to enhance access to knowledge and positive care-seeking behaviours.
Key recommendation
Action
- Establish anti-stigma legislation to protect the rights of people with mental illness and prevent discrimination.
- Create policies to improve organisational awareness and support structures .
- Provide referral pathways and counselling in workplaces to facilitate access to care if identified.
Key recommendation
Action
- Engage a wide variety of stakeholders in developing anti-stigma reduction interventions to ensure that they are appropriate for the cultural context.
- Use awareness campaigns, educational content, advocacy (both online and in-person) and media such as television and radio to address stigma and increase knowledge to improve access to mental health services in the community, schools and workplaces.
Key recommendation
Action
- Develop, test and implement mental illness stigma reduction interventions linked to mental health services reporting on any changes to service access and use.
- Campaign to increase global and local funding for research on mental health stigma reduction strategies targeting healthcare providers, users and carers.
Challenges
Challenge #1: Inadequacies in health care settings.
- Many health systems in LMICs do not fully support mental health care. Inadequacies include limited trained mental health personnel (psychiatrists, psychologists, counsellors, mental health nurses) and limited integration of mental health in primary health care (e.g. through sensitizing general healthcare practitioners and nurses on addressing mental health issues in routine practice). This can lead to stigmatizing attitudes by healthcare providers and medical students, hindering people with mental illness’ access to mental health services.
Challenge #2: Family members have limited knowledge on mental health and stigma.
- Low levels of community awareness around mental health disorders means that often times family members lack the necessary skills and knowledge on how to recognise symptoms or identify avenues of care for relatives with mental disorders.
- For many people with severe mental illness, their relatives are key in facilitating access to mental health care and as such should be a key target population for anti-stigma initiatives.
Challenge #3: Lack of laws and policies to protect people with mental illness.
- There is a general lack of stigma reduction laws and policies in many LMICs. Mental health legislation is essential in promoting the rights of people with mental illness, giving them the rights and means to accessing quality treatment in addition to protecting and empowering patients.
- Inadequate policies in the workplace also impede access, whereas the presence of these structured protective laws could help diminish institutional stigma by educating people about human dignity and rights.
Challenge #4: Negative cultural practices reinforce mental health stigma impeding access to services.
- Anti-stigma intervention strategies do not consider sociodemographic determinants of people with mental illness such as age, gender, knowledge, and attitudes specific to cultural settings that can contribute to the inaccessibility of mental health services.
- Literature suggests that ineffective mental health stigma reduction strategies lack adequate educational, outreach, and advocacy interventions to challenge inaccurate societal stereotypes regarding the causes of mental illness in the community.
Challenge #5: Limited research on reducing stigma towards mental health
- There is limited evidence and data analysis on what works when it comes to short-term and long-term strategies to eliminate mental illness-related stigma to improve access to health services
- Thus far, there is little research conducted on the impact of mental health stigma reduction programs on changing knowledge and beliefs at multiple levels (e.g. individual, community and institutional) in LMICs.
Finding the answers
This review of reviews searched multiple databases including PubMed, EBSCO Host and Google Scholar for literature review evidence on the topic of what works to eliminate stigma as a barrier to accessing health services for people with mental illness from both LMICs and HICs. The search strategy involved four key terms: mental illness, stigma intervention, health service and systematic review. Recommendations made for HICs were reviewed for transferability and feasibility in LMICs. This evidence note is based on the findings of 9 reviews from LMICs and 3 reviews from both HICs and LMICs.
Recommendations & actions
Key recommendation
Action
- Integrate mental health services into primary health care to reduce the treatment gap for people with mental disorders. Initiatives like the World Health Organization’s Mental Health Gap Action Programme has been used in many settings to implement these initiatives.
- Train general health care staff on mental health to reduce stigma and enhance access to mental health.
- Inclusion of mental health education in medical and nursing institutions’ curricula to improve knowledge and attitudes on mental health
Key recommendation
Action
- Prioritise relatives, neighbours and close social networks of people with mental illness in the design and implementation of anti-stigma reduction programs.
- Train health care workers, disabled peoples organizations (DPOs) and community leaders in promoting awareness of mental health stigma and treatment among people with mental disorders and family members to enhance access to knowledge and positive care-seeking behaviours.
Key recommendation
Action
- Establish anti-stigma legislation to protect the rights of people with mental illness and prevent discrimination.
- Create policies to improve organisational awareness and support structures .
- Provide referral pathways and counselling in workplaces to facilitate access to care if identified.
Key recommendation
Action
- Engage a wide variety of stakeholders in developing anti-stigma reduction interventions to ensure that they are appropriate for the cultural context.
- Use awareness campaigns, educational content, advocacy (both online and in-person) and media such as television and radio to address stigma and increase knowledge to improve access to mental health services in the community, schools and workplaces.
Key recommendation
Action
- Develop, test and implement mental illness stigma reduction interventions linked to mental health services reporting on any changes to service access and use.
- Campaign to increase global and local funding for research on mental health stigma reduction strategies targeting healthcare providers, users and carers.
Policy priorities
Mental illness stigma reduction strategies need urgent focus in policy formulation, implementation and evaluation to increase access to mental health services. Mental health stigma reduction strategies have the potential to address inadequacies in care-seeking, discriminatory practices in health care settings, support networks and legal policies when they are culturally adapted.
Conclusion
Reviews of interventions to address mental-illness related stigma as a barrier to accessing health services in LMICs are scarce. There is need for further research to develop comprehensive multi-level mental health stigma reduction strategies at individual, communal, institutional, organizational and structural levels to improve health care access for people with mental-illness.
Gaps & research needs
- There is an urgent need for more LMIC focus, as research from HICs or multiple settings may not always be generalised to other regions due to cultural variations and inequalities in financial and human resource capacities.
- There are glaring gaps on what multi-level strategies work in redressing mental health related-stigma as a barrier to health care access in LMICs.
- Furthermore, how stigma reduction strategies interact with task-sharing of mental health services in LMICs needs to be examined.
Acknowledgements
Peer Review: This brief was peer reviewed by Sarah Marks, Research Fellow at the International Centre for Evidence on Disability, LSHTM and Onaiza Qureshi, Knowledge Exchange Officer at Disability Evidence Portal.
Publication details: © London School of Hygiene & Tropical Medicine, November 2022.
Suggested citation: Javan Zaumambo Mokebo. Evidence Brief: What works to eliminate stigma as a barrier in accessing health services for people with mental illness in LMICs? Disability Evidence Portal, 2023.