- What are effective interventions for reducing stigma among health care providers who work with substance users?
Key take-home messages
- The attitudes and behaviours of practitioners have been linked to a variety of clinical outcomes in different patient groups (1, 2).
- The prevalence of stigma among health care providers towards people who use drugs is well-documented in the literature (3–8) and can result in barriers to healthcare access (9) and poor health outcomes (10, 11).
- There are limited evidence-based interventions to reduce stigma among health care providers who work with substance users (12, 13).
- The majority of identified interventions are educational, and appear to target stigma at a structural level; these include specialized training for health care students (14–17) and for professionals (9, 13, 18–22) who work directly with people who use drugs.
The issue and why it’s important
Stigma occurs when negative attitudes and behaviours are directed towards a person or group of people; this could be due to health, gender, sexual orientation, culture, race, or religion (23). Stigma is distinct from disapproval, as stigma is not necessarily linked to an individual’s attributes or behaviour; rather, stigma makes assumptions about an individual’s attributes or behaviour (24).
Stigma, in relation to health, is typically characterized by social disqualification, whereby individuals or groups are devalued and excluded because of a particular health problem (25). The extent to which medical conditions are stigmatized can vary significantly in social contexts (26). The stigma experienced by people who use drugs is unique (15) as individuals are perceived as having personal control over their illness, and are therefore held responsible and oftentimes blamed for their drug use (6, 27, 28).
Some research in the U.S. has shown that the general public holds significantly more negative views toward people with drug addiction when compared to people with mental illness (27). Health professionals also hold negative views toward people with drug use problems. One systematic review assessed the attitudes of health professionals in high-income settings towards people with substance use disorders, and found that health professionals commonly held adverse attitudes regarding patients with substance use disorders (10). Another systematic review found that health students hold people who use drugs with a low level of regard (3). The prevalence of stigmatizing attitudes among providers continues to be documented in Canada (8), the U.S. (5), and Australia (4).
The attitudes and behaviours of practitioners have been linked to a variety of suboptimal clinical outcomes in different patient groups (1, 2). Specifically for people who use drugs, this results in barriers to health care access (9) and poor health treatment outcomes (10, 11).
What we found
Fundamentally, anti-stigma interventions aim to demonstrate that negative behaviours and attributes are not applicable to all individuals of a social group (12). The majority of interventions we found appear to be structural, targeting health care students and providers.
There appears to be a lack of evidence-based interventions for practicing providers to reduce stigma toward people who use drugs. One author (in a 2018 publication) notes the paucity of literature in this area (13). One systematic review from 2012 identified evaluations of substance use disorder related stigma interventions (12). Thirteen studies were included in the descriptive synthesis; in all but one, a positive effect was observed on at least one stigma outcome measure. The majority of the included studies focused on medical students or professionals groups that have direct contact with substance users. Of note, the included studies in this systematic review are all older than ten years. One of the more recent publications in this study focusing on student providers is described:
- A study published in 2008 focused on reflection exercises in a psychiatry postgraduate training block at the University of Toronto (17). On the first day, residents were introduced to the reflective training component of the rotation, and were provided with a reflection journal and scholarly articles on the methods and benefits of using critical reflection in professional practice. Time in the rotation schedule was allocated for reflective activities. At the end of the rotation, residents submitted a final reflection paper. Qualitative analysis of 28 reflective narratives suggested that reflective practices established and enhanced self-awareness. Students found the practice valuable; authors concluded that reflective exercises should be used in clinical practice and developed as a professional competency.
Other, more recent studies, focused on individuals providing care for people who use drugs have also been identified. These interventions involved either incorporating a stigma-reduction component into a curriculum for students, or administering professional education training to staff who have direct contact with people who use drugs.
One study noted the lack of interventions to reduce stigma among practicing health providers and attempted to fill the evidence gap by delivering and assessing an online stigma reduction training module (13). This 40-minute interactive eLearning module titled ‘Stigma, Discrimination, and Injecting Drug Use’ was developed in partnership with national organizations that represent drug users in Australia. The aim of the module was to improve the relationship between health service providers and people who inject drugs by reducing discriminatory attitudes. It included personal narratives taken from real-life experiences of people who inject drugs, and included discussion on attitudes and behaviours towards this population. Providers were given a survey to measure their attitudes towards people who inject drugs. They were also asked to respond to hypothetical scenarios indicating how likely they were to support negative actions of others when working with people who inject drugs, both before and after receiving the module. In total, 139 participants completed the pre- and post-survey. Results indicated that after completing the online training module, attitudes of health care workers had changed and were less negative. Specifically, health care workers were less likely to support discriminatory attitudes depicted in three of the four scenarios presented in the module.
Another intervention evaluated the effectiveness of consumer-led training to improve the knowledge and understanding of staff who interact with individuals diagnosed with co-occurring mental health and substance use issues (21). In this controlled before-and-after study, the staff (i.e. reception, oral health, allied health, counselling, health care providers) of two community health sites in Melbourne, Australia, attended a four-hour baseline training session led by clinicians. Two months later, a three-hour consumer-led intervention, developed by seven individuals living with concurrent substance use and mental health issues, was delivered at one of the sites. Qualitative data was gathered in four waves using a survey. However, due to participant fatigue, only 31 participants completed the fourth wave at five-month follow-up, compared to 71 who completed the initial survey; 45 participants completed three waves. Authors concluded that consumer-led training by individuals with a dual diagnosis was associated with an increase in understanding among staff and persisted over time.
One Canadian project examined stigma directed at a specific population – Aboriginal women who use substances (18). A sample of interviews with substance use treatment providers were examined and verified with women who have lived experience. These interviews identified skills and traits essential in understanding the role stigma and cultural identity play in the healing journeys of these women. The final product was a fact sheet, appropriate for service providers working with Aboriginal women who use substances. The project was culturally based on the Seven Teachings of the Grandfathers, concepts foundational to the Aboriginal way of life (29). It also emphasizes the importance of a positive therapeutic alliance (i.e. the client-provider relationship), which has been shown to be a predictor of positive clinical outcomes in psychotherapy (30).
Additionally, The Centre for Addiction and Mental Health (CAMH) currently offers a course on stigma for healthcare providers (22). Titled “Understanding stigma: A free online course for healthcare providers and other frontline clinicians”, this 3-6 hour online learning module was developed in conjunction with Central Local Health Integration Networks and LOFT Community Services. The goal of the project is to improve interactions between healthcare providers and people with mental illness and addiction problems. Through instructional activities, the module aims to explore stigmatizing attitudes and behaviours through scenarios, interactive questions, and personal stories. While a formal evaluation of this module was not identified, it can be freely accessed at http://www.understandingstigma.ca.
Finally, we identified a protocol for a randomized controlled trial testing the effectiveness of an intervention to reduce stigma towards people with mental health and substance use problems among primary care staff working at community health centres in Toronto (9). The first author on the protocol was contacted via email and has suggested that a full publication of this intervention is expected in late 2018 (31). During this study, three community health centres acted as controls, and three received the intervention. The intervention consisted of staff training, raising awareness, and a recovery-focused art program to inform and support staff providing care for people with mental health and substance use problems. A variety of scales and interviews was used to further understand staff member’s beliefs and attitudes and the client’s perceptions of staff behaviours. A newsletter on this intervention, titled “The Acceptance Project”, was also identified in the grey literature and contains further details (20).
A search of the grey literature identified a training curriculum by the Harm Reduction Coalition titled “Understand drug-related stigma: Tools for better practice and social change” (19). This three-hour training was developed for community-based service staff who have direct contact with individuals who use drugs, however the training could also be for those interested in understanding and addressing drug-related stigma. Training includes understanding stigma, learning about the various ways drug users experience stigma and consequences of stigma on service access. Participants also gain practical tools in order to challenge pervasive attitudes and support the needs of drug users. The curriculum is available online (19) and the facilitator guide, participant workbook, and presentation materials are all available for free download.
Formal schooling curriculums
Additionally, some interventions have taken place among students in medical school.
One publication suggested that the ideal place to improve psychiatrists’ attitudes is with psychiatry residents (32). Two articles discuss the effects of a stigma-reduction educational intervention for physician assistant students working with people who use substances. Students (n=28) received three one-hour educational sessions during week six of a ten-week psychiatry course (15). The sessions consisted of lecture, discussion, direct interaction with a recovering substance user, viewing of a mainstream film, and written self-reflection. Student attitudes were measured using a modified version of the Attitudes to Mental Illness Questionnaire tool that included rating vignettes describing people with heroin or alcohol use disorders. Post-intervention, authors found that scores for the heroin vignette improved significantly pre-to-post test, and that this improvement was sustained after one year (14). However, post-test scores demonstrated that students attitudes, while improved, were still negative. This was verified by the written reflections, where discrimination persisted.
Another study examined the attitudes of resident physicians toward individuals with substance use disorders, and assessed the efficacy of an addictions medicine course to improve attitudes (16). This cohort study included 128 internal medicine residents at an academic medical centre in New York City. The intervention was an intensive 10-hour addiction course for first-year residents designed to increase knowledge and aptitude. The course included reading assignments, interactive sessions, lectures, use of screening tools, a field trip to a drug treatment facility, and involvement in Alcoholics Anonymous programming. Attitudes towards patients with alcoholism, dependence on narcotics, heartburn, and pneumonia were assessed pre- and post-test using the Medical Condition Regard Scale. When compared with heartburn and pneumonia, students had a lower regard for patients addicted to substances at baseline. After taking the course, there was a small but statistically significant increase in regard for patients with alcoholism, and a nonsignificant trend increase for patients with dependence on narcotics.
Other interventions of interest
Interventions targeting stigma reduction among the general population were sparse. Two articles were identified that may be useful when considering health care providers and stigma.
One study sought to reduce stigmatized attitudes towards those with schizophrenia and substance use disorders among the general public in the United Kingdom (33). Participants (n=400) were randomized to receive a short leaflet about a patient in remission that included a photograph of a man in a business suit or a simple description of a fictional patient. A five-item Attitudes to Mental Illness Questionnaire was used to measure the effect. Responses (n=310) demonstrated that the leaflet produced a large, statistically significant reduction in stigmatized attitudes towards individuals with opiate or alcohol dependence. There was also a statistically significant reduction in stigma towards people with schizophrenia.
An anti-stigma toolkit produced in 2012 by the Addiction Technology Transfer Center Network in the U.S., provides practical information and tools for the addiction treatment community (34). This guide is written in lay terms, and might function as a ‘primer’ for individuals unaware of how their own attitudes and actions may stigmatize others. The guide is to empower individuals to engage in stigma reduction efforts by providing them with tips, recommendations, tools, and resources. Additionally, the toolkit contains twelve worksheets at the end of Chapter 3 for a community group or individual to aid in mobilizing anti-stigma training or an awareness campaign.
What we did
We searched Medline and PsycInfo using a combination of (text terms stigma or discriminat* or MeSH term Social Stigma) and (text terms drug us* or injection drug use* or drug abuse or MeSH terms Intravenous Drug Usage or Drug Abuse or Substance Abuse, Intravenous or Substance-Related Disorders). Reference lists of identified literature reviews and systematic reviews were also searched. All searches were conducted on August 31, 2018 and results limited to English articles published from 2010 to present in high income counties. The search yielded 2,720 references from which 34 studies were included. Sample sizes of primary studies ranged from 25 to 3,326.
Factors that may impact local applicability
The evidence presented in this synthesis includes studies that focused on people who use drugs in high-income country settings, and among a variety of professional and non-professional populations; not all may work directly with people who use drugs. As a result, the interventions presented in this synthesis may not be universally appropriate or applicable. Additionally, the term ‘substance use’, as used in this synthesis, is not specific to a particular family of substances, and includes both licit and illicit entities. Finally, due to the paucity of literature, not all cited programs, interventions, or curricula have been rigorously evaluated. Therefore, caution should be used when considering implementation.
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Danielle Giliauskas and David Gogolishvili