Stigma and discrimination related to mental health and substance use issues in primary health care in Toronto, Canada: a qualitative study

ABSTRACT

Purpose: Community Health Centres (CHCs) are an essential component of primary health care (PHC) in Canada. This article examines health providers’ understandings and experiences regarding stigma towards mental health and substance use (MHSU) issues, as well as their ideas for an effective intervention to address stigma and discrimination, in three CHCs in Toronto, Ontario. Methods: Using a phenomenological approach, we conducted twenty-three interviews with senior staff members and peer workers, and three focus groups with front-line health providers. Ahybrid approach to thematic analysis was employed, entailing a combination of emergent and a priori coding. Results: The findings indicate that PHC settings are sites where multiple forms of stigma create health service barriers. Stigma and discrimination associated with MHSU also cohere around intersecting experiences of gender, race, class, age and other issues including the degree and visibility of distress. Clients may find social norms to be alienating, including behavioural expectations in Canadian PHC settings. Conclusions: Given the turmoil in clients’ lives, systematic efforts to mitigate stigma were inhibited by myriad proximate factors that demanded urgent response. Health providers were enthusiastic about implementing anti-stigma/recovery-based approaches that could be integrated into current CHC services. Their recommendations for interventions centred around communication and education, such as training, CHC-wide meetings, and anti-stigma campaigns in surrounding communities.

KEYWORDS:

• Mental illness
• addiction
• stigma
• recovery
• Canada
• primary health care

Acknowledgments

The authors would like to acknowledge the considerable assistance of the CHC liaison representatives. We are also grateful for the support and insights offered by the CHC staff who participated in the project. Funding for the research was provided by a Development and Dissemination Grant (Primary Health Care) from the Centre for Addiction and Mental Health.

Ethics Review

This study was reviewed and approved by the Research Ethics Board at the Centre for Addiction and Mental Health (REB Protocol Reference #190/2010-01).

Disclosure Statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

This research was funded by a Development and Dissemination Grant (Primary Health Care) from the Centre for Addiction and Mental Health (CAMH). The sponsor had no other role, and the project was conducted entirely by the WHO/PAHO Collaborating Centre for Addiction and Mental Health at CAMH.

Notes on contributors

Maureen A. Murney

Maureen A. Murney (PhD) is a social-cultural/medical anthropologist, and Lecturer in the Health Studies Program at the University of Toronto Scarborough. Both her research and teaching centre on notions of morality, personhood, and citizenship, as well as the ambiguities involving access to and the utilization of health care and health knowledge in Canada and Ukraine. She is currently working on the social-scientific component of a CIHR-funded project at the University of Manitoba, where she is analyzing survival strategies and identity-making among women experiencing HIV/HCV risk, violence, and other vulnerabilities, near the conflict zone in Ukraine.

Jaime C. Sapag

Jaime C. Sapag (MD, MPH, PhD) is a physician specializing in family medicine and public health. He has expertise in primary care, social epidemiology, mental health and substance abuse, and evaluation of health care services and systems. He is an academic in the Department of Public Health and Family Medicine at the Pontifical Catholic University of Chile, a Project Scientist for the Centre for Addiction and Mental Health (CAMH), and an Associate Professor at the School of Public Health in the University of Toronto, Canada.

Sireesha J. Bobbili

Sireesha J. Bobbili (MPH) is a Project Manager with the WHO / PAHO Collaborating Centre at the Centre for Addiction & Mental Health. She has extensive experience conducting international studies on stigma, the social determinants of health, and public health policy. She co-led a UN Women study exploring violence against women in Guyana, which is the focus of her PhD dissertation at the University of Toronto.

Akwatu Khenti

Akwatu Khenti (PhD) is an Assistant Professor with the Dalla Lana School of Public Health, University of Toronto. He formerly served as Assistant Deputy Minister for Ontario’s Anti-Racism Directorate, Cabinet Office, and Director of Transformative Global Health at the Centre for Addiction and Mental Health (CAMH). He has been involved in a wide variety of international research and capacity-building initiatives to strengthen mental health and addiction approaches for marginalized communities; and previously led CAMH’s specialized drug treatment and prevention programs for Black youth in Toronto, the Substance Abuse Program for African and Caribbean Youth (SAPACCY).