Core components of mental health stigma reduction interventions in low- and middle-income countries: a systematic review

Abstract

Aims: To identify and categorise core components of effective stigma reduction interventions in the field of mental health in low- and middle-income countries (LMICs) and compare these components across cultural contexts and between intervention characteristics.

Methods: Seven databases were searched with a strategy including four categories of terms ('stigma', 'mental health', 'intervention' and 'low- and middle-income countries'). Additional methods included citation chaining of all papers identified for inclusion, consultation with experts and hand searching reference lists from other related reviews. Studies on interventions in LMICs aiming to reduce stigma related to mental health with a stigma-related outcome measure were included. All relevant intervention characteristics and components were extracted and a quality assessment was undertaken. A 'best fit' framework synthesis was used to organise data, followed by a narrative synthesis.

Results: Fifty-six studies were included in this review, of which four were ineffective and analysed separately. A framework was developed which presents a new categorisation of stigma intervention components based on the included studies. Most interventions utilised multiple methods and of the 52 effective studies educational methods were used most frequently (n = 83), and both social contact (n = 8) and therapeutic methods (n = 3) were used infrequently. Most interventions (n = 42) based their intervention on medical knowledge, but a variety of other themes were addressed. All regions with LMICs were represented, but every region was dominated by studies from one country. Components varied between regions for most categories indicating variation between cultures, but only a minority of studies were developed in the local setting or culturally adapted.

Conclusions: Our study suggests effective mental health stigma reduction interventions in LMICs have increased in quantity and quality over the past five years, and a wide variety of components have been utilised successfully - from creative methods to emphasis on recovery and strength of people with mental illness. Yet there is minimal mention of social contact, despite existing strong evidence for it. There is also a lack of robust research designs, a high number of short-term interventions and follow-up, nominal use of local expertise and the research is limited to a small number of LMICs. More research is needed to address these issues. Some congruity exists in components between cultures, but generally they vary widely. The review gives an in-depth overview of mental health stigma reduction core components, providing researchers in varied resource-poor settings additional knowledge to help with planning mental health stigma reduction interventions.

Keywords: Discrimination; mental health; mental illness stigma; systematic reviews.

Fig. 1.

PRISMA flowchart of selection of articles and sources included in the review. *Authors contacted with no response

Fig. 2.

Framework of core components of anti-stigma interventions in low- and middle- income countries. The inner circle represents six overarching ‘categories’; the outer circle represents ‘components’ within each category; the boxes represent ‘sub-components’ within each component. Intervention methods are further broken down into ‘elements’ in Table 3. This framework of core components of anti-stigma interventions was developed by the authors as a composite of other analysis frames (Heijnders & Van Der Meij, ; Corrigan et al., 2013). *Intervention methods: the six sub-components are further coded into 32 elements; see Table 3. **Socio-ecological levels: based on Heijnders' framework (Heijnders & Van Der Meij, 2006). ***Cultural adaptation: ‘yes’ = local beliefs/culture are taken into account; the intervention at least partially originated from the local context; or, the intervention was piloted/field-tested

Fig. 3.

Duration of effective interventions and length of follow-up.