Evidence Summary: Interventions to Address Stigma in the Health System

Reducing stigma through mass-media (general population)

Narrative reviews of research on mental health stigma identified education- and/or contact-based mass-media campaigns that were associated with improved public attitudes and/or knowledge, including ‘Beyond Blue’ in Australia, ‘Time to Change’ in England, ‘Like Minds, Like Mine’ in New Zealand, and ‘Hjärnkoll’ in Sweden.^{Footnote 1Footnote 2}  Some were also associated with a reduction in discrimination reported by people living with mental illness, such as ‘Like Minds, Like Mine’ in New Zealand and ‘Time to Change’ in England.

Reducing stigma in media coverage (journalists)

A systematic review identified 27 studies from high-income countries that assessed 2 types of media-related interventions targeting mental illness stigma: media-monitoring projects or reporting guidelines, and education interventions for journalists or journalism students. Findings were mixed, and research quality was generally low. The most promising approaches appeared to be contact-based educational approaches and media guidelines developed and shared by authoritative institutions.^{Footnote 3}

Developing inclusive policies

In a longitudinal primary study conducted in the United States, civil union legalization was associated with lower levels of stigma consciousness, perceived discrimination, and depressive symptoms for women in Chicago who identify as lesbian or bisexual.^{Footnote 4}

Addressing stigma with healthcare providers and organizations

Narrative reviews of research on education- and/or contact-based interventions targeting mental illness stigma among healthcare providers found some evidence for short-term impacts related to attitudes, knowledge and/or intended behaviour.^{Footnote 1Footnote 2} The evidence base in this area is small.

A systematic review identified 21 interventions targeting mental illness stigma in health facilities in high-income countries.^{Footnote 5} Interventions were generally education- and/or contact-based and targeted healthcare students or healthcare providers. Findings for these interventions were promising, but mixed. Methodological variations across studies made it difficult for the authors to draw firm conclusions.

In a pooled analysis of 6 separate replications across Canada, the ‘Understanding Stigma’ program—a contact-based intervention—was associated with a decrease in mental illness stigma among healthcare providers, with an overall combined effect size of 0.30.^{Footnote 6} The replications used a quasi-experimental design, and some sites had small sample sizes.

A recent systematic review identified 2 interventions that focused on HIV stigma among health practitioners in high-income countries using education and/or skills-building. Findings for these interventions were promising, but mixed.^{Footnote 5}

A systematic review identified 7 studies with interventions targeting stigma towards people who use substances among medical students or other professionals (e.g., police officers, counsellors).^{Footnote 7} This included education and contact interventions, as well as critical reflection techniques, crisis intervention programs, and acceptance and commitment therapy training. Some findings were promising, though evidence was mixed. Studies had varying methodological quality.

A systematic review identified 4 interventions, all from high-income countries, intended to address stigma in health facilities related to substance use (or substance use and mental illness).^{Footnote 5} Interventions were generally education- and/or contact-based, targeting healthcare students and professionals. Findings were promising, but results and study quality were mixed. 

In a primary study completed in 4 Canadian primary health care clinics, the authors describe how they adapted their organizational-level health equity intervention (EQUIP) to incorporate an explicit harm reduction lens.^{Footnote 8} This equity-oriented approach to harm reduction included attention to the role of stigma and discrimination. In their primary study, the authors explore how this led to important discussions about substance use, and changes to organizational policy and practice.

A systematic review on implicit racial bias, including racial bias against African-American populations, identified a small research base—with mixed findings—on interventions to reduce implicit bias among healthcare providers.^{Footnote 9} The authors contextualized these findings within broader research on reducing implicit bias, and noted intervention types with potential relevance to healthcare providers, such as individuation and perspective-taking.

A narrative review on implicit bias, including implicit racial bias against African-American populations, identified common components of interventions, including self-reflection and approaches to control bias, such as perspective-taking, individuation, and looking for common-identity information.^{Footnote 10} Since this is an emerging field, the review focused on a synthesis of components rather than evidence of impact. The authors identified the need for more research to understand intervention effectiveness.

In a primary study completed in 4 Canadian primary health care clinics, an organizational-level health equity intervention (EQUIP) was associated with enhanced organizational capacity to provide equity-oriented health care to marginalized populations, including those living in poverty, facing homelessness, and those living with trauma, including Indigenous peoples.^{Footnote 8} The intervention focused on cultural safety, trauma- and violence-informed care, and organizational integration and tailoring. Intervention activities included staff education as well as organizational practice and policy change. The intervention was associated with increased staff confidence and awareness as well as organizational strategies to address racism, improved physical environment of the clinics, and changes to organization policies and practices. Research with a sample of patients at these clinics (41.7% of the sample identified as Indigenous) found that, over a 24-month period, higher levels of equity-oriented care was associated with greater patient confidence in health care, which was associated with greater patient confidence in managing health.^{Footnote 11} Greater patient confidence in managing their health was associated with improved health outcomes (depressive symptoms, PTSD symptoms, chronic pain, and quality of life).

A systematic review identified educational curricula and training initiatives intended to inform healthcare students and professionals on LGBT healthcare issues.^{Footnote 12} Most of the 15 included studies were from the United States. Interventions were associated with short-term improvements in knowledge, attitudes, and practice, but methodological quality was low for most studies.

A critical review of transgender stigma and health explored the potential of education and contact interventions to improve knowledge and attitudes among healthcare providers.^{Footnote 13} This synthesis explored the potential of various approaches, but this is an emerging field and few results were available.

A systematic search identified interventions from the United States, predominantly education- or contact-based, intended to reduce LGBT stigma, including some initiatives targeting healthcare providers. As this is an emerging field with little rigorous intervention research, the synthesis focused more on the components and activities of these interventions, rather than a detailed review of impact.^{Footnote 19}

Building cultural competence with healthcare providers and organizations

A systematic review of interventions to improve cultural competency related to patients with disabilities—with the vast majority of studies focused on mental illness—identified 25 interventions that targeted healthcare students or healthcare providers in high-income countries.^{Footnote 14} Interventions were predominantly contact- and/or education-based. Findings were mixed, research quality was generally low, and it was not possible to draw conclusions across studies.

A systematic review identified 23 articles that explored cultural competence interventions undertaken in the United States to address health disparities among racialized groups, including African-American populations.^{Footnote 14} Interventions included provider education, interventions to improve patient/provider interactions, and culturally tailored interventions. Low quality evidence made it difficult to draw conclusions about effectiveness.

An earlier review of 19 systematic reviews, in which some studies had a focus on African-American populations, identified a number of interventions intended to improve cultural competency in healthcare.^{Footnote 15} This included health practitioner training, culturally specific programs for patients, peer education, patient navigators, and exchange programs. Many initiatives were associated with changes in health provider knowledge, skills or attitudes or changes in patient health care access. Evidence was weaker for impact on patient outcomes. Methodological rigour was low among included studies.

A systematic review identified 16 studies of interventions to improve cultural competency in health care for Indigenous peoples, including: health provider and health student education; culturally specific health programs; and recruitment of Indigenous healthcare providers.^{Footnote 16} Study quality varied, and there were few rigorous evaluations. Some interventions were associated with increased healthcare provider confidence, health care accessibility and patient satisfaction.

A systematic scoping review identified 16 interventions intended to improve cultural competence with Indigenous and racialized peoples among healthcare workers.^{Footnote 17} Some interventions were associated with improvements in practitioner knowledge, skills or attitudes. There was limited evidence of impact on health care and health outcomes. Quality of evidence varied, with several studies of low quality included.

A systematic scoping review identified 15 studies of organization-level interventions to improve cultural competency with Indigenous and racialized groups, including two main types of initiatives: audit and quality improvement; and organization-level policy or practice change.^{Footnote 18} Some promising approaches were identified, but evidence quality was low.

A systematic review of cultural competence initiatives intended to improve culturally appropriate health care for populations who identify as LGBT identified 11 studies.^{Footnote 14} Interventions included training and skill-building for healthcare providers, among others. The strength of evidence was low, and no conclusions could be drawn from the review.

Building cultural safety with health providers and organizations

A scoping review of 30 publications identified the following components of cultural safety initiatives in Canada mainly focused on First Nations, Inuit and Métis peoples: collaboration/partnership; power sharing; addressing the broader context of the patient’s life; safe environment; organizational and individual level self-reflection; and training for healthcare professionals.^{Footnote 20} Since this is an emerging field, the review focused on synthesis of components rather than evidence of impact.

A scoping review of 6 articles on cultural competency and safety in Canadian hospital emergency departments recommended that initiatives: be developed in partnership with Indigenous communities and with the recognition of colonialism and its impacts; train practitioners in relationship-building and self-awareness; focus on the needs of patients who face barriers accessing non-emergency health services; and work to prevent discrimination.^{Footnote 21} The review focused on synthesis of barriers and facilitators rather than evidence of impact.

Reducing stigma through contact and education interventions

Systematic and narrative reviews suggest education and/or contact interventions are often associated with short-term to medium-term knowledge improvements and/or attitudinal improvements related to mental illness stigma.^{Footnote 1Footnote 2Footnote 22Footnote 23} Methodological and intervention quality varied across studies. In some reviews, contact was identified as more effective than education, whereas the impact of both approaches was similar in other reviews.^{Footnote 2Footnote 22Footnote 23}

One recent systematic review included a meta-analysis of interventions to reduce stigma related to severe mental illness.^{Footnote 23} Methodological quality varied. After adjusting for publication bias, contact interventions were associated with reductions in stigmatizing attitudes (d = 0.24) and desire for social distance (d = 0.40). Education interventions were associated with reductions in stigmatizing attitudes (d = 0.30) and desire for social distance (d = 0.27).

A systematic review identified stigma reduction efforts intended to improve knowledge and reduce negative attitudes towards people living with HIV.^{Footnote 24} While the scope of the systematic review was worldwide, the review identified many studies from the United States and some in Canada. Most interventions were education-based. The review included a meta-analysis of 42 studies. This identified significant improvements in HIV knowledge (Cohen's d = 0.48 from interventions with control groups; Cohen's d = 0.42 for those without control groups) and attitudes towards people living with HIV (Cohen's d = 0.39 from intervention with control groups; Cohen's d = 0.25 without control groups) among participants. However, many studies lacked methodological rigour.

An earlier systematic review identified 48 articles, from across the world, reviewing interventions intended to reduce HIV stigma and discrimination.^{Footnote 25} While most took place in low- or middle-income countries, some interventions were implemented in the United States or Canada. Interventions were identified at various levels, but education, skill-building, and contact interventions were most common. Many studies were promising, and research quality varied but was generally high. 

A systematic review identified 3 studies of education and contact interventions with promising, but mixed, impacts on stigma attitudes towards people who use substances. The review included a small number of studies, and quality of research varied.^{Footnote 7}

Addressing implicit bias

A systematic review identified 30 articles of interventions to reduce implicit bias, particularly implicit Black/White racial bias. While evidence was mixed, and the quality of evidence varied, some approaches were identified as promising, such as intentional strategies to overcome biases, evaluative conditioning, identifying with the outgroup, and exposure to counter stereotypes.^{Footnote 26}

Challenging internalized stigma

One systematic review of interventions designed to reduce internalized mental illness stigma identified 14 studies. Five of these studies were eligible for inclusion in meta-analysis.^{Footnote 27} The pooled standardized mean difference (SMD) for three psychosocial interventions was − 0.43, a small to moderate impact on internalized stigma among people living with severe mental illness. However, issues in study quality were identified.

A systematic review of 5 randomized control trials (RCTs) suggested the effectiveness of interventions targeting self-stigma among people who live with mental illness was uncertain, in part due to heterogeneity and risk of bias.^{Footnote 28} A previous critical review identified 14 studies, including some promising interventions, but the quality of research was too low to draw firm conclusions.^{Footnote 29}

A systematic review identified 23 studies of interventions intended to reduce self-stigma experienced by people living with HIV, as well as their families.^{Footnote 30} Most studies took place in North America, and most studies targeted adults living with HIV. Psychoeducational interventions were most common, including educational, skill-building, empowerment, and social support approaches. While some findings were promising, results were mixed and the quality of the studies varied. The review identified few interventions that focused on family members of people living with HIV.

A more targeted systematic review identified 5 studies exploring interventions intended to address intersectional stigma experienced by African/Black diasporic women living with HIV.^{Footnote 31} Interventions included emotional writing disclosure (EWD), behavioural interventions focused on knowledge and coping, and a participatory educational intervention focused on knowledge and skill-building. Most interventions were associated with reductions in HIV-related stigma. However, sample sizes were small, studies were heterogeneous, and firm conclusions cannot be made.

A systematic review identified 3 studies of interventions that targeted self-stigma among people with substance use disorders. This included acceptance and commitment therapy, skills training and vocational counseling, as well as plastic surgery to remove needle track-marks. There were few studies and the quality of research varied, but some findings were promising.^{Footnote 7}

A systematic search identified interventions from the United States, particularly cognitive behavioural and narrative interventions, intended to improve coping resources among populations who identify as LGBT.^{Footnote 19} As this is an emerging field with little rigorous intervention research, the synthesis focused more on the components and activities of these interventions, rather than a detailed review of impact.

A critical review of transgender stigma and health explored the potential of therapeutic, coping, and social support interventions to address self-stigma among populations who identify as transgender.^{Footnote 13} While some findings are promising, this is an emerging field and few results were available.

Considerable variation

Stigma research is quite varied, with different conceptualizations of stigma, intervention types, target populations, and outcome measures. Though the breadth of initiatives is an encouraging recognition of the importance of addressing stigma, the diversity of approaches makes it difficult to draw firm conclusions. 

With so many different approaches, it is challenging to advance understanding and interventions in the stigma field overall.^{Footnote 39Footnote 40} While there is a need to balance a focus on what is unique between and also within stigmatized groups, there is potential for interventions that target stigma across health conditions and social identities or other characteristics.^{Footnote 5 Footnote 14Footnote 21Footnote 41Footnote 53}

Little focus on long-term impact

Little stigma intervention research has explored the long-term impact of interventions, including their impact on behaviour change or how stigma reduction could reduce health inequities.^{Footnote 1Footnote 2Footnote 7Footnote 12Footnote 14Footnote 15Footnote 16Footnote 17Footnote 18Footnote 23Footnote 24Footnote 26Footnote 27Footnote 31Footnote 40Footnote 42Footnote 43Footnote 44Footnote 45Footnote 46}

Need for more rigorous intervention development

The research base on stigma lacks strong intervention development. A greater focus on incorporating theory, lived experience and existing knowledge about ‘what works’ is necessary for developing evidence-based and equitable interventions.^{Footnote 1Footnote 5Footnote 12Footnote 23Footnote 26Footnote 27Footnote 28Footnote 45}

Methodological limitations

There are a number of methodological limitations in stigma intervention research, particularly a lack of rigorous research methods.^{Footnote 1Footnote 5Footnote 7Footnote 9Footnote 16Footnote 17Footnote 18Footnote 23Footnote 25Footnote 26Footnote 36Footnote 37Footnote 45Footnote 47} This includes reliance on self-report measures, lack of generalizability in study population, selection and/or attribution bias, inadequate focus on what works for different groups (e.g., by age, gender) and lack of randomization.

Much of the research focuses on self-reported changes in attitudes, knowledge or intended behaviour, rather than objective measures or reported experiences of stigma and discrimination.^{Footnote 2Footnote 17Footnote 23Footnote 24Footnote 43Footnote 44Footnote 48} Outcomes and perspectives of those with lived experience with stigma are infrequently included in evaluation activities.^{Footnote 2Footnote 9Footnote 14Footnote 15Footnote 16Footnote 17Footnote 42Footnote 43}

Need for greater focus on population-level and multi-level interventions

While there has been little research on the structural, organizational, or policy changes required to address stigma and discrimination, efforts at these levels have the greatest potential to create change.^{Footnote 1Footnote 5Footnote 13Footnote 14Footnote 15Footnote 16Footnote 26Footnote 28Footnote 31Footnote 36Footnote 37Footnote 45Footnote 47Footnote 49Footnote 50Footnote 51} 

Calls for action at the structural level are often linked to a wider discussion about the importance of multi-level interventions that concurrently address stigma across levels.^{Footnote 5Footnote 13Footnote 39Footnote 40Footnote 43Footnote 45Footnote 47Footnote 50Footnote 52}

Need for greater focus on intersectionality

Stigma and discrimination research often exists in silos.^{Footnote 39Footnote 40} The lives of people who experience stigma cannot be separated into discrete categories, as many experience overlapping stigmas. Some research reviews explore multiple stigma topics, but there has been little focus on how to understand and address co-occurring stigmas.^{Footnote 5Footnote 14Footnote 40} The lens of intersectionality can deepen understanding of stigma and inform the development of interventions relevant for populations experiencing co-occurring stigmas.^{Footnote 14Footnote 25Footnote 31Footnote 40Footnote 50}