Innovation summary

The global burden of disease for mental illness and substance use problems is enormous. Many populations around the world are affected. For instance, approximately 32% of people with severe mental illness do not access health care services in Peru.1 One of the main factors impacting accessibility is stigma associated with mental illness and substance use.  It is a major barrier to timely and high quality mental health care. Regardless of the need, very little work has been done in this area and few evidence-based anti-stigma tools are currently available to primary health care providers.

The proposed innovation aims to reduce stigma and discrimination among primary health care providers toward individuals with mental illness and substance use problems in Lima, Peru, by implementing a comprehensive anti-stigma intervention. Originally developed and tested by CAMH in Toronto, Canada, this intervention was culturally adapted for the Peruvian context using a participatory action approach.

The five components of the intervention include:

  • Developing local teams of leaders
  • Innovative contact-based training
  • Analysis of policies and procedures
  • Recovery-based arts
  • Raising awareness in the community

Once it’s effectiveness has been proven, the intervention is expected to be progressively scaled-up across the country.


Impact summary

  • Approximately 180 primary health workers will participate in innovative contact-based training for mental health and substance use problems
  • 300 health care workers will be exposed to the intervention
  • 1000 clients with a mental illness and/or addiction diagnosis will be screened

“The training with the psychiatrist, help us to see the stigma within us toward people with mental illnesses. We thought that he was a patient who had no solution, that there was no change, that he could not get any better. We have realized in the training that clients can recover and can get re-inserted in society”.

- Head of a primary health centre


Innovation details

The innovation is a comprehensive anti-stigma and discrimination intervention for primary health care workers who deliver care to persons with mental illness and substance use problems. There is an emphasis on a recovery oriented approach in service provision. The five components of the intervention are as follows:

Developing local teams of leaders

The local team of leaders or champions at each primary health care centre includes primary health care workers and in most of the cases the head of the centre. This component was critical for adapting the components of the intervention (contact-based training, analysis of organizational policies and procedures for stigmatizing content, raising awareness of mental illness-related stigma in the community, and recovery-based arts) to the Peruvian cultural context as well as generating buy-in for the intervention by staff at participating primary health care centres.

Innovative contact-based training

Training includes key anti-stigma and recovery principles along with specific mental health and substance use topics relevant to primary health care providers. Using an adult education model, modules have been tailored according to results from situational assessments of each centre, and recognized best practices. A special emphasis on cultural perspectives and values has been integrated into the training. A total of twelve-hour workshops were held at each primary health care centre.  A client with a mental illness participated in the trainings.

Analysis of policies and procedures

The analysis of policies and procedures aimed to evaluate strengths and areas for improvement in service delivery for individuals with mental illness and substance use problems. Recommendations were provided to each centre in order to promote changes for improving access and quality of care of healthcare service users who present these conditions.

Recovery-based Arts

Team of local leaders of two centres selected painting for their primary health care centre. Individuals with mental illness, who access primary healthcare services, worked with staff members, to create art based on the experience of stigma, discrimination, acceptance and recovery. In one centre volunteer health promoters (community members who link people with services) and staff members participated in the group of art. At the end of a ten session workshop series, participants presented their work to staff and clients at each centre.

Raising awareness

A video was used to increase awareness about stigma and recovery for people with mental illness and substance use problems in the community.  The video portrayed the daily life of a person who lives with a mental illness and how she is coping with the illness and promoting her recovery. It also showed the components of the intervention.


Key drivers

Involvement of the different divisions of the Ministry of Health

Involving the different divisions of the Ministry of Health at the National and Local levels, generated support for the intervention. This has the potential to promote sustainability and scalability at regional and national levels, aligned with national mental health program performance measures.

Organizing joint activities with the Ministry of Health

Throughout the innovation, joint seminars have been organized in order to raise awareness of the implementation and evaluation of the intervention among government authorities.  For instance, personnel of the Ministry of Health, Ministry of Education, Ministry of Women and Vulnerable Populations, Ministry of Social Inclusion and Development, municipalities, universities, colleges of physicians (psychologist, nurses, and midwives), scientific organizations (such as the Peruvian psychiatry association) and NGOs have played a role attending seminars. 

It was important that the intervention was well known for networking purposes, but also for profiling the resulting evidence. This evidence has the potential to be used during the annual planning phase of the “Budget Based on Results” programs of the Ministries.



  • Structural changes at the Ministry of Health
  • Turnover of staff
  • Stigma prevented people with lived experience to participate fully



The research project was designed, implemented and evaluated as a sustainable and scalable program. We are working towards the inclusion of the proven intervention as part of the activities of the “Budget Based on Results” mental health program of the Ministry of Health.




Key Partners:

Ministry of Health (Peru):

  • Mental Health National Office
  • Institute of Management of Health Care Services (IGSS)
  • Health Care Network of SJM –VMT and some of their Primary Health Care Centres  (PHCC)
  • Health care network of VES, Lurin, Pachacamac and Pucusana and some of their PHCC
  • Institute of Health Service Management

Evaluation methods

Cluster Randomized Control Evaluation using mixed methods

The intervention was evaluated as a cluster randomized control trial. Six primary health care centres were randomized into the intervention group, and six centres were selected as controls.

Health care workers answered surveys that measure stigma immediately before and after the intervention. Interviews with authorities, health care providers (professionals), relatives/significant others of individuals with mental illness and substance use problems, and people with mental illness and substance use problems who access services at the centres, were conducted before the intervention and  after the intervention.  Focus groups discussions with health care workers (professionals and non-professionals) of the intervention and control primary health care centres were also carried out before and after the intervention.  The focus groups aimed to explore collective perceptions and experiences regarding stigma toward users with mental illnesses.


Cost of implementation

The total cost of the implementation and evaluation of the intervention was approximately CAD $250,000.


Impact details

192 primary health workers participated in innovative contact-based training for mental health and substance use problems. 600 health care workers were exposed to the intervention.
204 clients more received psychological care in two of the intervention sites compared with baseline.

The intervention group showed lower stigma attitudes toward people with mental illness and addiction than the control group in the Mental Illness: Clinician’s Attitudes Scale (MICA).

Qualitative data indicates: a) Improvement in early identification of Mental Illness and/or Substance Use Problems (MISUP) cases in primary health care. b) Clients perceived some positive changes regarding stigma among health care providers. c) Health care providers realized that people with MISUP can recover and that it is worthy to provide care to them.


  1. Piazza, M. y Fiestas, F. (2014)  Prevalencia Anual de Trastornos y Uso de Servicios de Salud Mental en el Perú: Resultados del Estudio Mundial de Salud Mental.  Rev. Perú Med. Exp. Salud Pública, 31(1): 30-8 
  2. Stuart H, Arboleda-Florez J, Sartorius N. (2012) Paradigms Lost: Fighting stigma and the lessons learned. New York: Oxford University Press Inc.
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