Background: Relative to those without mental illness, patients with serious mental illness (SMI) are less likely to receive preventive services (vaccinations and screening mammography) and specialty physical healthcare services (cardiovascular procedures, hip replacement, pacemaker insertion, hospitalization for diabetic patients, and surgical treatment for cancers). While the reasons for this pattern are complex, providers negative attitudes and behaviors and lower clinical expectations have been implicated. Our HSR&D study (IIR- 08-086) of stigmatizing attitudes and behaviors of VA mental health and primary care (PC) providers showed that providers have lower expectations for persons with SMI regarding their ability to adhere to treatment, make treatment decisions, and understand educational material; and refer them less often to services such as weight reduction programs. Moreover, PC providers exhibited more negative attitudes (stereotyping and blaming the individual for mental illness) towards persons with SMI compared to mental health providers. Research shows that interventions which utilize an experiential approach to challenge stereotypes by exposing people to high functioning persons with mental illness called contact interventions yield significantly greater reduction in stigmatizing attitudes than other approaches such as education alone. A recent literature review identified 22 contact interventions, including 8 randomized controlled trials which targeted stigma among different populations including healthcare providers. Contact intervention in each study significantly reduced stigmatizing attitudes. Thus contact based strategies provide an evidence-based approach to reduce provider stigma, and potentially reduce disparities in receipt of medical services. In consultation with an expert in stigma reduction, Dr. Patrick Corrigan, utilizing qualitative data from VA providers and feedback from a National advisory board of providers and consumers who have SMI, we have tailored an evidence-based contact intervention, Serving All Veterans Equally (SAVE) for PC providers. Objectives: We will use a Type 2 Hybrid effectiveness-implementation design to test the feasibility and impact of using an external facilitation strategy (EFS) to support implementation of the evidence-based contact intervention, SAVE, to reduce stigma of mental illness among VA PC providers. Methods: We will partner with the PC services at Central Arkansas Veterans Healthcare System, Little Rock, AR and Veterans Health Care System of the Ozarks, Fayetteville, AR and recruit PC providers from an available pool of 75 and 45 PC providers respectively. Using EFS based on the Promoting Action on Research Implementation in Health Services (PARIHS) framework we will assist PC partners in designing and tailoring an implementation strategy to local context and resources, with processes during the implementation phase to support, monitor, problem-solve and refine implementation as needed. A process evaluation will gather qualitative data on stakeholder perspectives and experiences with the EFS and the contact intervention. The RE-AIM model will serve as the framework for guiding our selection of measures for this study. Feasibility of the EFS to implement the contact intervention will be assessed by Reach (proportion of eligible primary care providers receiving the contact intervention) and Adoption (the number and proportion of eligible PC providers receiving BOTH the baseline and booster sessions) of the intervention. Fidelity of the contact intervention will be assessed using a multidimensional approach that has been used in previous contact intervention trials. For assessing fidelity of the EFS, we will document an initial local implementation plan and changes to the implementation plan undertaken to support implementation of the contact intervention. To assess impact of the contact intervention on provider attitudes, we will utilize measures of social distance and attribution of mental illness. We will measure change in provider expectations, behavioral intentions and clinical behaviors using a vignette-based survey and administrative data.
Primary care (PC) providers' stigmatizing attitudes and behaviors towards persons with serious mental illness (SMI) have been implicated as one of the contributing factors that cause disparities in healthcare for these patients, including studies with VA patients. Our HSR&D study (IIR-08-086) also showed that PC providers, compared to mental health providers, have more negative attitudes towards persons with SMI. Building on our study findings, and responsive to VA Uniform MH Services Handbook and Office of Mental Health Operations' (OMHO) and `Improve Veterans Mental Health Sustainment and Transition Plan', this Rapid Response Project (RRP) will test implementation of an evidence-based contact intervention (Serving All Veterans Equally (SAVE) to reduce stigma of mental illness in VA PC providers. We will leverage results from this RRP pilot to conduct a larger scale QUERI hybrid type 2 effectiveness-implementation trial to test implementation of the SAVE intervention within additional VISNs and VAMCs.
