Department of Psychology, University of Zurich, Zurich, Switzerland.
Department of Psychiatry, George Washington University, Washington, DC, USA.
Epidemiol Psychiatr Sci. 2018 Sep 4;29:e3. doi: 10.1017/S2045796018000458.
This systematic review compiled evidence on interventions to reduce mental health-related stigma in primary health care (PHC) in low- and middle-income countries (LMICs). Studies targeting PHC staff (including non-professionals) were included. Primary outcomes were stigmatising attitudes and discriminatory behaviours.
Data collection included two strategies. First, previous systematic reviews were searched for studies that met the inclusion criteria of the current review. Second, a new search was done, covering the time since the previous reviews, i.e. January 2013 to May 2017. Five search concepts were combined in order to capture relevant literature: stigma, mental health, intervention, PHC staff and LMICs. A qualitative analysis of all included full-texts was done with software MAXQDA. Full-texts were analysed with regards to the content of interventions, didactic methods, mental disorders, cultural adaptation, type of outcome measure and primary outcomes. Furthermore, a risk of bias assessment was undertaken.
A total of 18 studies were included. Risk of bias was rated as high in most included studies. Only six studies had tested their intervention against a control condition, two of which had used random allocation. Most frequently used interventions were lectures providing theoretical information. Many studies also used interactive methods (N = 9), discussed case studies (N = 8) or used role plays (N = 5). Three studies reported that they had used clinical practice and supervision. Results of these studies were mixed. No or little effects were found for brief training interventions (e.g. 1 h to 1 day). Longer training interventions with more sophisticated didactic methods produced statistically significant changes in validated stigma questionnaires. These results have to be interpreted with caution due to risk of bias. Methods for cultural adaptation of interventions were rarely documented.
More rigorous trials are needed in LMICs to test interventions that target discriminatory behaviours in relationship with patients. Cultural adaptation of stigma interventions and structural/institutional factors should be more explicitly addressed in such trials.
本系统评价汇集了在中低收入国家（LMICs）初级卫生保健（PHC）中减少与心理健康相关的污名的干预措施的证据。研究对象为 PHC 工作人员（包括非专业人员）。主要结果是污名化态度和歧视行为。
数据收集包括两种策略。首先，搜索了以前的系统评价，以寻找符合当前评价纳入标准的研究。其次，进行了新的搜索，涵盖了以前评价以来的时间，即 2013 年 1 月至 2017 年 5 月。为了捕获相关文献，合并了五个搜索概念：污名、心理健康、干预、PHC 工作人员和 LMICs。使用 MAXQDA 软件对所有纳入的全文进行定性分析。对全文进行分析，内容包括干预措施、教学方法、精神障碍、文化适应、结果测量类型和主要结果。此外，还进行了偏倚风险评估。
共纳入 18 项研究。大多数纳入的研究风险偏倚评估结果为高。只有 6 项研究将其干预措施与对照条件进行了比较，其中 2 项使用了随机分配。最常使用的干预措施是提供理论信息的讲座。许多研究还使用了互动方法（N=9）、讨论案例研究（N=8）或使用角色扮演（N=5）。有 3 项研究报告称，他们使用了临床实践和监督。这些研究的结果喜忧参半。简短的培训干预措施（例如 1 小时至 1 天）几乎没有效果或效果不大。使用更复杂教学方法的较长培训干预措施在验证过的污名问卷中产生了统计学上显著的变化。由于存在偏倚风险，这些结果需要谨慎解释。干预措施文化适应方法很少有记录。
需要在 LMICs 中进行更严格的试验，以测试针对与患者关系中的歧视行为的干预措施。在这些试验中，应更明确地解决污名干预措施的文化适应和结构/制度因素。
