Problem
Stigma and discrimination against people with mental health disorders is a significant public health issue in Tunisia. Stigma related to mental health disorders exists in the health care system and among health care providers. For people living with mental health disorders, it is a major barrier to seeking help, accessing quality care and treatment, and recovery. Data from the Mental Health Atlas 2017 show that health care providers working in general health care receive limited mental health-related training in Tunisia. Therefore, implementing innovative solutions for health care providers to improve interactions between them and people living with mental health disorders and quality of care is crucial. Consequently, a group of psychiatrists from Razi Hospital – part of The INDIGO Network – launched the Responding to Experienced and Anticipated Discrimination (READ) anti-stigma training for medical students at Tunis Medical School in 2017. The INDIGO Network is a collaboration of research colleagues in over 30 countries worldwide committed to developing knowledge about mental illness-related stigma and discrimination, both in terms of their origins and their eradication.
Development
The Responding to Experienced and Anticipated Discrimination (READ) training, originally developed by King’s College London, comprises evidence-based interventions for medical students to address mental health-related stigma. These interventions have been tried and tested in high-income countries and found to be effective. To this regard, the group of psychiatrists (part of The INDIGO Network) adapted these interventions to the Tunisian context, creating the Tunisia READ training which aimed to improve the ability of future doctors, specifically fifth-year medical students at Tunis Medical School to overcome the stigma of mental health disorders and improve quality of care and life for people living with mental health disorders. The Tunisia READ training is the first time ever to grow the skills of future doctors through early introduction of interventions for reducing mental health-related stigma.
Main goals of the Tunisia READ training
Improve stigma-related knowledge, as well as attitudes related to mental illness and psychiatry.
Increase constructive responses to experienced and anticipated discrimination among people living with mental health disorders.
Reduce behaviours which are or can be experienced as discriminatory by people with mental health disorders and carers.
Test effectiveness of this intervention among medical students during their psychiatry rotation.
Process
The Tunisia READ training adapted the original training, incorporating examples from the Tunisian culture and data from studies addressing stigma and discrimination in people living with mental health disorders in Tunisia. Additionally, the case scenarios for the role plays were rewritten to fit the Tunisian context. All content was delivered to medical students at Tunis Medical School in French. Medical students were divided into groups, 10 to 12 students per group, and each group received two training sessions. Ideally, the training is designed to be co-delivered by a mental health professional and a person with lived experience – which was unfortunately not possible in Tunisia. Instead, the training was adapted to include a video of a person living with a mental health disorder, explaining their lived experience of access to care and treatment, impact of stigma and discrimination on their daily life, and how to deal with and prevent discrimination.
Contents of the training
There were 115 (out of 450) fifth-year medical students from Tunis Medical School in the training, which comprised two sessions. The first of the two sessions was one-and-a-half hours long and was delivered to medical students before they started their psychiatry rotation. The first session comprised:
a video of a person living with a mental health disorder, explaining their lived experience of access to care and treatment, impact of stigma and discrimination on their daily life, and how to deal with and prevent discrimination;
a presentation on the different forms of stigma and its impact on people living with mental health disorders;
a video testimonial from a service user from Time to Change, a UK-based social movement to change the way people think and act about mental health problems; and
two role plays, one on experienced discrimination (i.e. a personal experience with discrimination), and one on anticipated discrimination in a professional setting (i.e. when an individual limits his or her activities on account of fear of discrimination).
At the end of the first session, students were asked to identify situations they observed around experienced or anticipated discrimination or reported by service users in the psychiatry department for discussion in the second session. The second session was one hour long and was delivered to medical students 1 to 2 weeks after the first session (and before they completed their psychiatry rotation). The second session comprised:
a discussion of situations medical students observed around experienced or anticipated discrimination or reported by service users in the psychiatry department;
a presentation on mental health disorders among health care providers, how to support them and how students can care for their own mental health; and
a role play where students assumed the role of a primary health care provider discussing a diagnosis of psychosis with a service user and trying to convince them to seek specialized help.
Evaluation
Evaluations were conducted pre- and post-training to measure: knowledge and understanding of medical students regarding stigma related to mental illness; attitudes of medical students about psychiatry and people living with mental illness; and skills of medical students in a clinical setting such as communication skills. Different measurement scales and tools were used. The Mental Health Knowledge Schedule (MAKS) scale was used to measure knowledge and understanding, while the Mental Illness Clinicians’ Attitudes version 2 (MICA2) scale was used to assess attitudes, and the Objective Structured Clinical Examination (OSCE) tool was used to assess skills.
Impact
Based on the assessments conducted pre- and post-training, evidence shows that the Tunisia READ training was effective in improving the knowledge and understanding of medical students at Tunis Medical School regarding stigma related to mental illness, and their attitudes about psychiatry and people living with mental illness, as well as their communication skills. Here are some testimonials from fifth-year medical students that took part in the training.
Challenges
Pre-implementation challenges included engaging people with lived experiences and cultural adaptation of the READ training. People with lived experiences of mental disorders were unwilling to physically take part in the training because of personal experiences of stigma and discrimination. While they shared videos of their experiences still, their physical presence would have been more effective. Also, adapting the READ training to Tunisia and its culture was particularly difficult however, even if time and resources are scarce, no implementation should occur without cultural adaptation.
Implementation challenges included preparedness of trainers and attitudes of medical students. While trainers were mental health professionals still, there is a need for them to hone their skills for this particular training. Also, some of the medical students demonstrated defensive attitudes when confronted with the reality of stigmatizing attitudes among health care providers, which requires trainers to tackle more carefully in future implementation.
Lessons learnt
Engage people with lived experiences of mental health disorders to improve knowledge, understanding and attitudes of medical students and outcomes for people living with mental health disorders.
Adapt trainings to the country and its culture even if time and resources are scarce. No implementation should occur without cultural adaptation.
Find the right trainers for the project to improve results, including reduce defensiveness, help others learn and manage their knowledge and skills effectively.
Integrate the READ training into other schools across the country, to reduce the stigma related to mental health disorders among future doctors and health care providers, and to improve outcomes for people living with mental health disorders and break down the barriers to help-seeking, accessing quality care and treatment, and recovery.
Continuation
The group of psychiatrists (part of The INDIGO Network) who launched the READ training in Tunisia are working to integrate the training into the curricula of Tunis Medical School, starting academic year 2022/2023, targeting fifth-year medical students during their psychiatry rotation. The results of the assessment also show potential for integrating the READ training for reducing the stigma of mental health disorders in other medical schools across the country as well as adapting it for use in schools of nursing and health sciences.
References and additional information
C. Henderson, J. Noblett, H. Parke, S. Clement, A. Caffrey, O. Gale-Grant, B. Schulze, B. Druss and G. Thornicroft, “Mental health-related stigma in health care and mental health care settings,” Lancet Psychiatry, 2014.
D. Cohen, S. J. Winstanley and G. Greene, “Understanding doctors' attitudes towards self-disclosure of mental ill health,” Occupational Medicine, 2016.
E. Heim, C. Henderson, B. A. Kohrt, M. Koschorke, M. Milenova and G. Thornicroft, “Reducing mental health-related stigma among medical and nursing students in low- and middle-income countries: A systematic review,” Epidemiology and Psychiatric Sciences, 2019.
G. Thornicroft, N. Mehta, S. Clement, S. Evans-Lacko, M. Doherty, D. Rose, M. Koschorke, R. Shidhaye, C. O’Reilly and C. Henderson, “Evidence for effective interventions to reduce mental health-related stigma and discrimination: Narrative review,” Lancet, 2016.
J. C. Kane, M. A. Elafros, S. M. Murray, E. M. H. Mitchell, J. L. Augustinavicius, S. Causevic and S. D. Baral, “A scoping review of health-related stigma outcomes for high-burden diseases in low- and middle-income countries,” BMC Medicine, 2019.
L. C. Potts, I. Bakolis, T. Deb, H. Lempp, T. Vince, Y. Benbow, W. Waugh, S. Kim, S. Raza, C. Henderson and The INDIGO READ Study Group, “Anti-stigma training and positive changes in mental illness stigma outcomes in medical students in ten countries: A mediation analysis on pathways via empathy development and anxiety reduction,”, Social Psychiatry and Psychiatric Epidemiology, 2022.
S. Clement, O. Schauman, T. Graham, F. Maggioni, S. Evans-Lacko, N. Bezborodovs, C. Morgan, N. Rüsch, J. S. L. Brown and G. Thornicroft, “What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies,” Psychological Medicine, 2015.
T. Deb, H. Lempp, I. Bakolis, T. Vince, W. Waugh, C. Henderson and The INDIGO READ Study Group, “Responding to experienced and anticipated discrimination (READ): Anti-stigma training for medical students towards patients with mental illness, study protocol for an international multisite non-randomised controlled study,” BMC Medical Education, 2019.