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Chapter 7
Evaluation ofanOnline Intervention
toReduce Stigma Among Healthcare
Workers inLatin America
JazmínMora-Rios, HugoNoelValdivia Ramos, JimenaKalawaski,
andJoséLuisVázquez
7.1 Introduction
It is recognized throughout the world that stigma represents one of the major barri-
ers to the care of people with mental health problems, including substance use.
From highly industrialized to less developed countries, stigma related to mental
illness affects the emotional well-being of those suffering from mental disorders
and also of their families. Stigma causes isolation and shame, which discourages
people from seeking help.
In his classic study on stigma, Goffman (1963) dened the concept as a negative
and degrading personal attribute that differentiates a person from others, placing
them in an undesirable or inferior category, which leads to feelings of guilt, shame,
and humiliation.
Society attributes a series of negative traits to people who suffer from mental
health problems, especially those with severe conditions such as schizophrenia and
addiction (Sordi etal., 2021; Monteiro etal., 2013; Mora-Ríos etal., 2017). These
people are often criticized and discredited, assumed to be unpredictable and danger-
ous, perceived as having no control over their lives, and blamed along with their
J. Mora-Rios (*)
Direction of Epidemiological and Psychosocial Research. Ramón de la Fuente Muñiz
National Institute of Psychiatry, Mexico City, Mexico
e-mail: morarj@inprfm.gob.mx
H. N. Valdivia Ramos
National Autonomous University of Mexico, Mexico City, Mexico
J. Kalawaski · J. L. Vázquez
Demand Reduction Unit, Executive Secretariat of the Inter-American Drug Abuse Control
Commission (CICAD), Organization of American States (OAS), Santiago, Chile
e-mail: JKalawski@oas.org; JVazquez@oas.org
86
families for their condition. Mental illness generates fear, rejection, pity, and mis-
trust. These ideas are promoted in the social imaginary through the family, media,
political gures, and opinion leaders.
These negative beliefs are held both by the general population and by healthcare
workers. Some studies have reported that healthcare workers have a fatalistic per-
ception of mental health problems (Schulze, 2007), believing that it makes no sense
to invest in treatment because they affect people who “cannot be cured”; they think
the only possible forms of care are connement and control through medication,
especially in the case of disorders such as schizophrenia and substance abuse
(Murney etal., 2020). Rojas Vistorte etal. (2018) found greater stigmatization by
older and more experienced healthcare workers. Negative attitudes were found
more in medical personnel than in those in other elds, especially concerning disor-
ders such as schizophrenia and depression. There was also a directly proportional
relationship: the greater the degree of stigmatizing attitudes, the greater the ten-
dency to express rejection and create social distance from people with these prob-
lems. Among the reasons that could explain this stigmatization by healthcare
workers, it has been suggested that mental health is emphasized less than physical
health in their training as students, which could lead to a limited and fragmented
approach to health, with less humanized care.
Studies have shown attitudes of rejection even in mental health specialists
(Arvaniti etal., 2009; Lauber etal., 2006). However, direct contact with people with
mental illness seems to reduce stigma in the attitudes of health professionals more
than scientic knowledge (Clement etal., 2012; Couture & Penn, 2003; Knaak
etal., 2014; Smith & Cashwell, 2011).
This study is part of a global comparative and cross-cultural research network
since 2004. The overall goal of the network is to achieve multidisciplinary advances
in research on stigma and the dynamics of structural discrimination and social
exclusion in mental illness. Mexico joined this initiative in 2007. Funding was
obtained from the Sectoral Funds for Health and Social Security Research
(FOSSSIS-CONACYT) to carry out a broad-based study on stigma and discrimina-
tion in mental illness in different parts of the population, including people with a
psychiatric diagnosis, families, healthcare workers, and the general population. The
goal was to develop a community intervention model based on the needs of the main
actors involved in the treatment and rehabilitation of people with a mental disorder,
with a gender and human rights approach, to generate action strategies in this sector.
The Mexico study found that participants with a psychiatric diagnosis identied the
family as the primary source of stigma and discrimination and health care workers
as secondary. These ndings prompted our interest in developing the proposal for
the online course (Mora-Rios etal., 2017).
The objective of the course is to sensitize those who work in health institutions,
as they are key to transforming the conditions of care and improving the quality of
life and inclusion of people affected by mental health problems. We seek to provide
resources and undertake actions that expand knowledge on these topics and make
them accessible to people who provide health care. The course is aimed at
J. Mora-Rios et al.
87
professionals from health teams in rst-level care institutions in Latin America,
although it may also interest auxiliary healthcare workers.
The objective of this study was to evaluate the effect of this online intervention
for healthcare workers aimed at reducing stigmatizing attitudes toward mental ill-
ness and to identify whether such intervention constitutes a valuable resource for
healthcare workers of 13 Latin American countries, 2017.
7.2 Development
The methodology of the broader research project, from which the online course was
devised, has already been published (Mora-Ríos etal., 2013; Mora-Ríos & Bautista,
2014). The project was approved by the Ethics Committee of the Ramón de la
Fuente Muñiz National Institute of Psychiatry. Written informed consent was
obtained through the process, guaranteeing the anonymity and condentiality of the
information. The online course is called “Stigma and Mental Health: Challenges in
Constructing Quality Health Care.” It was implemented with the support of the
Sectoral Funds for Health and Social Security Research (Mora-Ríos etal., 2017).
The rst course was given in 2018 to 107 healthcare workers.
This study analyzes the course results from 1 September to 26 November 2021,
administered with the support of the Education Department of the Ramón de la
Fuente Muñiz National Institute of Psychiatry. The course was offered remotely
using the MOODLE platform.
7.3 Course Description
The contents of the course are divided into ve modules: (1) What do we know
about mental health?, (2) Stigma and its consequences for health, (3) Expressions of
stigma and discrimination in clinical practice, (4) What can we do?, and (5)
Recommendations. To provide dynamic content, infographics, audio, and videos
were included, presenting the testimonies of people with lived experience of mental
health disorders; these used professional actors to protect the identities of the infor-
mants on whose participation they were based. Testimonies from family members
and others with lived experience and from healthcare workers were also included.
The course had 16 individual activities and nine group activities (participation in
forums).
In response to an announcement by the Demand Reduction Unit of the
Executive Secretariat of the Inter-American Commission for the Control of Drug
Abuse (CICAD), 75 participants from 12 different countries in Latin America
(Argentina, Brazil, Chile, Costa Rica, Colombia, Ecuador, Guatemala, Mexico,
Nicaragua, Panama, Peru, and Uruguay) enrolled and were sent usernames and
passwords. Of these, 9% never signed into the platform, and 11% of those who
7 Evaluation of an Online Intervention to Reduce Stigma Among Healthcare Workers…
88
signed in performed no activities in the course. The course was offered free of
charge, and participants were asked to consent to use their answers for research
purposes. They were asked to perform all activities to receive a certicate at the
end of the course.
7.4 Sociodemographic Characteristics ofParticipants
Table 7.1 shows data for those who completed the course. The majority were women
(76%), and the rest (24%) were men from 12 countries, mainly from Mexico (20%),
Peru (12.7%), and Panama (10.9%). Their ages were 24–65, with an average age of
39; 60% were aged 31–44, so they were generally young. The disciplines repre-
sented were psychology (65%), medicine (13%), nursing (12%), social work (5%),
and others (e.g., sociology). The most common level of studies was a master’s
degree (40%), followed by bachelor’s and specialty degrees (33% and 22%, respec-
tively). One participant from the nursing area with a high school diploma works in
an addiction center in Mexico. Approximately 76% of participants reported work-
ing in the care of people with mental health problems.
7.5 Measurements
The following measurements were used to assess attitudes toward mental illness:
1. Six items from the Mental Health Knowledge Schedule (MAKS-10; Evans
Lako, et al., 2010) were used. The original version consists of 12 items measur-
ing general mental health knowledge. For this study, we used a ve-point
agreement- disagreement response format on a Likert scale. The questionnaire
measures six areas of knowledge related to stigma based on six items: help-
seeking, recognition, support, employment, treatment, and recovery. A higher
score corresponds to a greater understanding of the stigma of mental illness.
2. Reported and Intended Behavior Scale (RIBS; Evans-Lacko etal., 2011). This
scale originated from the Star Social Distance Scale (Evans-Lacko etal., 2011)
and measures intended behavior. It consists of eight items, of which the rst four
have a three-point response range (yes, no, and don’t know). The remaining four
items measure the intention of behavior and are answered on a ve-point Likert
scale indicating the level of agreement and disagreement. The highest score indi-
cates less stigmatizing behavior. In this study, only the last four items were con-
sidered, maintaining the original contexts, and a new one was added, the
willingness to have a relationship.
3. The Opinions Toward Mental Illness (OMI) questionnaire was initially devel-
oped by Cohen and Struening (1962). It consists of 51 items that evaluate ve
dimensions: authoritarianism, benevolence, mental health ideology, social
restrictiveness, and interpersonal etiology of mental illness. The overall reliabil-
J. Mora-Rios et al.
89
Table 7.1 Sociodemographic characteristics of participants who completed the course
Women Men Total
n % n % n %
Age (years)
24–30 5 9.1 1 1.8 6 10.9
31–37 11 20 6 11 17 30.9
38–44 11 20 5 9.1 16 29.1
45–51 11 20 – – 11 20
52–65 4 7.3 1 1.8 5 9.1
Nationality
Argentina 1 1.8 – – 1 1.8
Chile 5 9.1 – – 5 9.1
Colombia 2 3.6 1 1.8 3 5.5
Costa Rica 2 3.6 – – 2 3.6
Ecuador 2 3.6 3 5.5 5 9.1
Guatemala 4 6.7 1 1.8 5 9.1
Honduras 2 3.6 – – 2 3.6
Mexico 9 15.0 2 3.6 11 20.0
Nicaragua 2 3.6 1 1.8 3 5.5
Panama 6 10.9 – – 6 10.9
Peru 4 7.3 3 5.5 7 12.7
Uruguay 4 7.3 – – 4 7.3
Profession
Psychology 29 69.0 7 12.7 36 65.5
Medicine 4 7.3 3 5.5 7 12.8
Nursing 5 9.1 2 3.3 7 11.7
Social work 2 3.6 1 1.8 3 5.5
Other 2 3.6 – – 2 3.6
Level of education
High school – – 1 1.8 1 1.8
Bachelor’s degree 16 29.1 2 3.6 18 32.7
Specialty 5 9.1 7 12.7 12 21.8
Master’s degree 19 34.5 3 22 40.0
Doctorate 2 3.6 – – 2 3.6
Works in care
Yes 32 58.2 10 18.2 42 76.4
No 10 18.2 3 5.5 13 23.6
Total 42 76.4 13 23.6 55 100
ity was 0.83. The response format is a four-point Likert scale: 0=totally dis-
agree, 1 = disagree, 2 = agree, and 3 = totally agree. The overall internal
consistency is adequate (alpha=0.90). For this study, we used a modied ver-
sion based on the version validated in Mexico by Altamirano (2012), which was
previously adapted to the context of the Mexican population (Mora-Ríos
etal., 2013).
7 Evaluation of an Online Intervention to Reduce Stigma Among Healthcare Workers…
90
The participants completed all the questionnaires before the rst training session
of the intervention group (August 2021) and after the completion of the last training
session (October 2021). Five instructors, three women and two men, reviewed the
activities and provided support and guidance. Participants met with the team in two
online sessions, the rst at the beginning of the course to provide information about
the platform and activities to be developed and the second to give feedback to the
participants regarding doubts about the activities or platform.
7.6 Data Analysis
The t-test for related samples was used to compare the means between the pre-test
and post-test phases for hypothesis testing. The magnitude of the differences was
evaluated using the effect size (Cohen’s d), interpreted according to the reference
values small=0.2, moderate=0.5, and large=0.8 (Lakens, 2013). This analysis
included the MAKS, the RIBS, and the OMI scores. The assumption of normality
was veried using the Shapiro-Wilk test. The data were analyzed using the statisti-
cal programs JASP version 0.19.1 (JASP Team, 2024) and G*Power version 3.1.9.7
(Erdfelder etal., 1996).
7.7 Results
The majority of the participants evaluated the course favorably (60%). All showed
interest in the course topics. In addition to reading, each participant carried out
activities. There were forums where participants could share their reections and
experiences about how stigma and discrimination were expressed in their respective
countries.
Table 7.2 shows the comparison of the means of the total scores of the question-
naires on mental health stigma: the MAKS, the RIBS, and the OMI.These were
administered in the pre-test and post-test phases. Signicant differences were found
between the means of the pre-test and post-test in the MAKS, with a moderate effect
Table 7.2 Comparison of the means of the stigma questionnaires in the pre-test and post-test
Scale
Pre-test Post-test
t (df) p-value SE 1-βM SD M SD
Mental health
knowledge schedule
24.25 2.24 25.81 2.42 −4.318 (54) <0.001 −0.58 0.99
Reported and intended
behavior scale
21.01 2.64 22.30 2.57 −3.830 (54) <0.001 −0.51 0.97
Opinions toward
Mental Illness (OMI)
questionnaire
171.56 14.42 182.52 11.58 −6.526 (54) <0.001 −0.88 0.99
Note: Student’s t-test. Cohen’s d effect size
J. Mora-Rios et al.
91
Fig. 7.1 Distribution and density of the results of the stigma questionnaires between phases. Note:
This gure shows the distribution and density of the scores of the Mental Health Knowledge Scale
(MAKS), Reported and Intended Behavior Scale (RIBS), and the Opinions toward Mental Illness
(OMI) questionnaire in the pre-test and post-test phases. The box and whisker plots show an
increase in the medians of the scores after the intervention. The density graphs indicate a shift
toward higher scores in the post-test phase, suggesting improved knowledge, behavioral intention,
and a favorable change in opinions about mental illness
size, t(54)=−4.318, p<0.001, 95% CI [−2.290, −0.838], d=−0.58, and statistical
power (1−β)=0.99. As shown in Fig.7.1, most participants had increased scores
after the intervention, suggesting greater knowledge about mental health stigma at
the course’s end.
Signicant differences were also observed for the RIBS, with a moderate effect
size, t(54)=−3.830, p<0.001, 95% CI [−1.967, −0.615], d=−0.51, and statistical
power (1—β)=0.97. Figure7.1 shows an increase in the mean scores for intended
behavior in the post-test, as indicated by the upward-trending lines in the connected
dot graph and the increase in the post-test medians, reected in the box plots.
Finally, there was a signicant increase in the post-test scores of the OMI ques-
tionnaire, with a large effect size, t(54)= −6.526, p <0.001, 95% CI [−14.332,
−7.596], d=−0.88, and statistical power (1–β)=0.99. Figure7.1 shows an increase
in the post-test scores for most participants, suggesting that favorable attitudes
toward mental illnesses increased after the intervention.
Participants were asked if the course could be a resource to reduce the stigmatiz-
ing attitudes of healthcare staff in their countries. As seen in Fig.7.2, 95% of partici-
pants said it had helped them greatly, and three said it had helped somewhat. More
than a specic change in attitudes, what was achieved was a strengthening of the
7 Evaluation of an Online Intervention to Reduce Stigma Among Healthcare Workers…
92
Fig. 7.2 Evaluation of the online course Stigma and Mental Health
positioning of the participants and a reection on their experiences with other par-
ticipants in the forums included in the course.
Note: This gure shows the evaluation of the usefulness of the intervention for
modifying discriminatory attitudes and practices in health care workers. The bars
indicate that most participants rated the ve modules positively, with the last two
being the best rated.
In addition, participants were asked open-ended questions. One question asked
whether they would recommend the course to others, and nearly all replied that they
would. They also said that the course was helpful in their professional and personal
training and enabled them to expand their knowledge on stigma and discrimination
and consider how to apply them. They said that the course sensitized them by
encouraging them to identify and reect on their beliefs and strengthening their
competencies, resources, and possible strategies. By contrasting the testimonies
with their reality, they said, the course helped them to analyze the situations they
had experienced and to sensitize them to their own stigmatizing attitudes and dis-
criminatory actions in the past. One example is given related to benevolent stigma,
or treating with pity the person with mental health problems or addiction, which
could underestimate their abilities. In comments about the activities, most said that
they liked being able to put the material reviewed into practice. Below are some
examples of reasons given as to why they would recommend the course:
I would recommend it because it helped me expand my perception of the topic and make
changes. Anyone taking this course will at least have to reect on their attitudes.
Yes, because one has to be sensitized. It also helps us grow as people since when we
have a relative or someone close to us, we have the tools to provide the help they need.
Yes, because it incorporates up-to-date practical and theoretical information that is valu-
able and applicable to Latin American reality.
The feedback from our coordinator also made me reect and think. It is very complete.
J. Mora-Rios et al.
93
Participants also recommended including examples of community interventions to
combat stigma from different parts of Latin America, mainly related to substance
use; providing more material on inequality, interculturality, human rights, and pub-
lic policy; adding more detailed information on people in vulnerable groups; such
as migrants, people living on the streets, and the LGTTTBIQ+ community; expand-
ing on topics related to employment and structural discrimination; and including
strategies to involve communications and social media. These are all complex and
interesting topics, and they demonstrate the interest in Latin America in understand-
ing the forms and manifestations of stigma in the local context.
The aspects of the course most valued by participants were the videos, video
animations, and testimonials (of healthcare workers, family members, and sub-
stance users), as they allowed them to identify expressions of stigma in their work
environments and their effects on people and to learn more about people’s needs.
One participant emphasized that it was good to know that all the testimonials were
based on real cases. Participants also criticized the format of two activities sug-
gested by the platform (nos. 11 and 16) and suggested carrying the activity out
freely. These suggestions helped improve the course.
7.8 Final Considerations
This study found that this online course is helpful in reducing stigmatizing attitudes
in healthcare workers. The course content is culturally relevant for healthcare work-
ers in Mexico and other parts of Latin America. Stigma and discrimination in health
care are widespread problems in different regions of Latin America (Semrau, et al.,
2015, Sordi et al., 2021). Participants showed interest in the course and highlighted
the importance of training healthcare workers on these issues, especially in pri-
mary care.
These ndings coincide with those of Valdivia (2024), who demonstrated the
effect of this course in modifying the attitudes of healthcare students at the end of
and 1month after completing the course. In this work, we evaluate only the effect
of the intervention after the course has ended. One of the future tasks suggested by
this experience is a follow-up study over a more extended period, at 1 month,
6months, and a year after the intervention, to evaluate whether the favorable atti-
tudes are maintained over time, as has been done in other studies (Clement etal.,
2012; Knaak etal., 2014). This intervention and its effectiveness constitute impor-
tant contributions specially considering that in recent years, efforts to address stigma
in, Latin America through anti-stigma iniciatives have increasingly been recognized
(Thornicroft etal., 2022).
Our ndings on the effectiveness of this course highlight the importance of pro-
viding quality comprehensive training to healthcare workers, with collaboration
between the health team and others who participate in care in such elds as medi-
cine, psychology, nursing, and social work. The training information should be up-
to- date, based on scientic evidence, and use non-stigmatizing language. The use
7 Evaluation of an Online Intervention to Reduce Stigma Among Healthcare Workers…