Cross-cultural adaptation of four instruments to measure stigma towards people with mental illness and substance use problems among primary care professionals in Chile.

Stigma toward people with mental illness and substance use problems is a significant global concern, and prevents people with these conditions from accessing treatment, particularly in primary health care (PHC) settings. Stigma is a cultural phenomenon that is influenced by particular contexts and can differ by country and region. The majority of stigma research focuses on Europe or North America leading to a lack of culturally relevant stigma research instruments for the Latin American context. The present study describes and discusses the methodology for cross-culturally adapting four stigma measurement scales to the Chilean context. The cross-cultural adaptation process included nine phases: (1) preparation; (2) independent translations; (3) synthesis 1 with expert committee; (4) focus groups and interviews with researchers, PHC professionals, and PHC users; (5) synthesis 2 with expert committee; (6) independent back translations; (7) synthesis 3 with expert committee; (8) pilot with PHC professionals; and (9) final revisions. The adaptation process included an array of diverse voices from the PHC context, and met three adaptation objectives defined prior to beginning the process (Understandability, Relevance, and Acceptability and Answer Options). The resulting, culturally adapted questionnaire is being validated and implemented within PHC settings across Chile to provide in-depth insight into stigma among PHC professionals in the country. The authors hope it will be useful for future research on mental illness and substance use stigma in similar settings across Latin America.

Reducing stigma toward mental illness and substance use issues in primary health care in Chile: Protocol of a cluster controlled trial study.

Background: Chile is implementing a Community Mental Health Model with a strong role of primary health care (PHC). PHC has great potential to early detection and provision of accessible and coordinated services to people who present mental illness and/or substance use issues (MISUI). However, stigma toward people with MISUI among PHC professionals is a significant barrier to accessing good quality of care. A wealth of literature supports the importance of reducing stigma for this population. The main goal of this research project is to determine the effectiveness of a comprehensive anti-stigma intervention in reducing stigmatizing attitudes and behaviors among PHC providers toward individuals with MISUI in the Chilean context, using Centros de Salud Familiar (CESFAMs) as the point of intervention. Methods: The intervention is based on an initiative that was previously developed in Canada and then also pilot-tested in Lima, Peru, with the Center for Addiction and Mental Health (Ontario, Canada). The model will be culturally adapted with CESFAM PHC provider and user inputs to be relevant and valid to Chile. The 18-month intervention includes five (5) components that are simultaneously implemented in CESFAMs: (1) Develop a Team of Local Champions in each intervention CESFAM, comprising PHC providers and users; (2) Analysis of Internal CESFAM Policies, Procedures, and Protocols to determine areas of improvement in service delivery for individuals with MISUI; (3) Raising Awareness of stigma toward MISUI using various forms of media within the CESFAM; (4) Innovative Contact-Based Education workshops on anti-stigma and recovery principles, co-lead by academic/clinical trainers and a person with lived experience of MISUI; and (5) Recovery-Based Arts, a multi-week arts workshop for PHC providers and users to produce artwork related to MISUI and recovery, culminating in an exhibition to showcase artwork for the CESFAM providers, users, and community. The expected intervention outcomes are the following: Participation in the experimental group will result in a significant decrease in stigmatizing attitudes among PHC providers toward individuals with MISUI compared with the control group as measured by the Chilean version of the Opening Minds Scale for Health Care Providers Scale (OMS-HC); Participation in the experimental group will result in a significant decrease of PHC users experiences of stigma conveyed by PHC providers compared with the control group as measured by the Internalized Stigma of Mental Illness (ISMI) scale, validated for the Chilean population. The changes in attitudes and behaviors within the experimental group will be sustained over time as measured at 6 months-follow-up. To evaluate the effectiveness of this 18-month intervention, a 4-year, two-arm, cluster-randomized controlled trial is proposed, with CESFAMs being the unit of randomization (or "cluster"). Implementation Science approach will be taken to measure relevant implementation outcomes for each component of the intervention, and through qualitative data collection with CESFAM providers and authorities. Data analysis will be carried out using SAS 9.4 (specifically, using POC MIXED and PROC GENMOD) and R 3.5. Mixed-effect modeling will used for both PHC provider and user data, which will include individuals and CESFAMs as random effects and group (intervention/control) as fixed effects. Discussion: This study represents a new stage of relevant and innovative research in mental health and stigma in Chile that will contribute to improving access and quality of care for people with MISUI. Evaluating the impact of the intervention model and its implementation will provide the necessary tools to scale the intervention up to other CESFAMs across Chile. Clinical trial registration: [www.ClinicalTrials.gov], identifier [NCT05578066].

What matters most': stigma towards severe mental disorders in Chile, a theory-driven, qualitative approach.

BACKGROUND: Stigma towards severe mental illness manifests in different ways across cultures and only recently has a theoretical perspective emerged to understand such cultural differences. The 'What Matters Most' framework identifies culturally specific dimensions of stigma by identifying the interactions between cultural norms, roles, and values that impact personhood. OBJECTIVE: This study explores the cultural underpinnings that create and maintain stigmatizing attitudes towards severe mental illness in Chile. METHODS: In-depth interviews developed using the 'Scale of Perceived Discrimination and Devaluation', and the 'What Matters Most' framework were conducted with twenty people identified as having a severe mental illness. Interviews were coded and discussed until agreement was reached, then analyzed by an independent reviewer to determine inter-rater reliability. RESULTS: A key factor shaping stigma among women was the loss of capacity to accomplish family roles (i.e. take care of children).or men, cultural notions of 'Machismo' prevented them from disclosing their psychiatric diagnosis as a means to maintain status and ability to work. A protective factor against stigma for men was their ability to guide and provide for the family, thus fulfilling responsibilities attributable to 'Familismo'. Social appearances could play either a shaping or protecting role,contingent on the social status of the individual. DISCUSSION: In Chilean culture, stigma is rooted in gendered social characteristics and shared familial roles. Interventions should aim to address these norms and incorporate culturally salient protective factors to reduce stigma experienced by individuals with serious mental illness in Chile and other Latin American settings.