Community level

Although SUs did not report stigmatising attitudes at the PHC level, these findings should be subject to further investigation, because understanding the socioeconomic backgrounds and the dire needs of all SUs interviewed could explain the positive feedback we received from them. The fear of losing a free or semi-free support with all their medical related concerns could have influenced their answers, despite undergoing a consent process in which they were informed that care would not be affected by the responses they gave. In addition, another factor contributing to their exclusively positive descriptions of interactions with PHC staff could have been social desirability.

Koschorke and colleagues (2021) [22] provide recommendations to address these potential sources of biases when researching mental health stigma; they suggest not conducting qualitative interviews in clinical settings. Ideally, such interviews could be conducted in community settings, and persons with lived experience of MHCs could be trained to conduct the qualitative interviews. Another consideration is that PHC staff did not display discriminatory behaviour when the patients were present at the centre but waited the patients to leave and discussed internally their conditions and pointed on their behaviours.

The low level of stigma within healthcare centres, as reported by SUs, is also in line with a very recent study in Lebanon by Karam et al. [26] that investigated barriers to care through a sample of representative household adults: < 6% mentioned that stigma is a barrier to treatment. Rather, the greatest barrier to treatment is the low perceived need, as observed in 73.8% of the cases.

On the other hand, experiences of stigma in the community were prominent and voiced repeatedly by SUs. SUs felt unsupported by their community, families and partners as well, experiencing discrimination, hurtful labelling, and an internalization of negative beliefs about the self. These findings are in line with a recent study in Lebanon exploring cultural misconceptions about MHCs among Lebanese university students, [27] which found that 70% of the students believed that MHCs are taboo in Lebanese culture and should be hidden from family members. Several studies revealed widespread discrimination against patients with MHCs by family members, relatives, neighbours and the community throughout Arab countries, the MENA region, Asia and worldwide (e.g. [28,29,30]). Very few individuals in Arab countries are able to seek treatment from MHPs, and it may take years after onset before they seek care [31, 32]. In line with SUs’ reports and these aforementioned studies, it is clear that the discrimination from family members towards SUs would be an important topic for future research.

Other types of discriminatory behaviours linked to nationality, ethnicity, and sexual orientation are intimately linked to development of MHCs. In fact, since the start of the conflict in Syria, PHC centres in underdeveloped and marginalized areas became hubs of support for Syrian refugee families. With little and often ineffective work done on social cohesion between already underprivileged host-communities and the Syrian refugee communities [33, 34], the existing stigmatisation based on nationality, culture and traditions exacerbated the MHCs of these communities. Mental health problems were often reported to be directly linked to social determinants such as living conditions and poverty [35], as well as overt aggression from host communities (e.g., neighbours or employers) towards Syrian refugees and other ostracized communities (LGBTQI).

PHC level

At the PHC level, many providers stated that recently stigma in society had diminished significantly due to increased knowledge and awareness around MHCs. This could be a result of increased activities on different fronts and from different MH actors to increase awareness and tackle stigma, including the work of the NMHP. However, it is important to continuously address further interpersonal stigma by increasing the level of awareness about mental health in the general public in Lebanon.

Contrasting reports from staff with those from MHPs indicated that stigma related to MHCs remains a barrier to care. A comparison between the interviews with nurses on the one hand and GPs on the other hand revealed that nurses did not openly describe events of discrimination against patients with MHCs, while doctors were more outspoken regarding this issue. They clearly expressed that patients with MHCs were a burden on the centre, and that their treatment should be handled by specialists or in institutionalised settings. The latter statement is in line with a study in Oman [36], where both medical students and the public preferred that psychiatric care facilities should be located away from the community.

These differences between nurses and GPs regarding their degree of open disclosure of stigma may be a by-product of their power and authority disparities, highlighting a pertinent power gradient in the medical field [37]. In most Arab countries, the literature shows that the reverence for physicians dominates over that for nurses, forming a weak image of nurses in Lebanon and the surrounding region [38]. Disclosing negative attitudes toward patients with MHCs may place nurses at greater risk for losing their jobs than physicians.

Primary care providers’ discussions of the challenges of treatment highlights implicit negative attitudes towards patients with MHCs. Some providers and managers shared such negative beliefs, such as believing that patients with MHCs are violent and thus deserving of blame for their conditions. According to the literature, this perspective has previously been seen to be a conceivable reaction to the misperception that MHCs are a personality weakness or that individuals are to be blamed for their disorder [39, 40]. Hence, this attitude may be considered an indication that service providers have misconceptions without voicing them explicitly, an assumption that should be further investigated. Consistent with findings by Ross and Goldner [11], the predominant attitude amongst nurses was that physical healthcare must be prioritized over mental healthcare, as it is seen as an additional burden to their job or was ‘not their job’. This attitude toward primary mental healthcare is likely aggravated by the lack of financial incentives.

In regard to interventions, awareness messages should be disseminated at the PHC level, particularly through evidence-based interventions. The existing evidence-base for high-income countries suggests that structured social contact between healthcare providers and persons with lived experience of MHCs has the potential to reduce stigma [41]. One strategy that has been piloted in LMICs is the Reducing Stigma among Healthcare Providers (RESHAPE) intervention in which people with lived experience are trained using Photo Voice to tell recovery stories. The visual recovery narratives presented by the persons with lived experience as well as other forms of structured social interaction of persons with lived experience are incorporated into mental health trainings for PHC staff. A pilot study showed that incorporating these social contact components into PHC trainings reduced stigma, increased MHC diagnostic accuracy of HCPs, and increased willingness to endorse and deliver psychological and psychosocial treatments (i.e., not solely rely upon medication) [42, 43]. The RESHAPE intervention is now being piloted in Tunisia, Ethiopia, India, and China. This work highlights that assessments of stigma should not be limited to only self-reported attitudes, but that behavioural assessments such as clinical role plays [44] and documentation of clinical services should also be evaluated during stigma interventions for HCPs.

System level

As already mentioned, stigma can be implicitly found in nurses’ and physicians’ behaviour. However, this stigma can also be found explicitly within statewide policies [11]. A study by Reed and Fitzgerald [45] revealed that “mental healthcare may often be left till last, only carried out if there is still time, and only by those who feel able”. This also confirms that discriminatory policies and structural procedures prevent treatment seeking and funding for mental healthcare, therefore heavily influencing structural stigma [30, 39, 46, 47]. Similar findings regarding the overall importance of structural stigma in shaping other forms of stigma have been identified in other LMICs [48].

According to the interviews, training and supervision were highly emphasized as key to improving primary care providers’ knowledge on mental health and, in turn, to reducing stigma. This is consistent with the review conducted by van Boekel et al. [49], who highlighted that training, supervision and policies will improve structural factors and will have advantageous influences on the attitudes of HCPs. To intervene at a structural level, several factors need to be considered, including the revision of work policies, procedures, and job descriptions by PHC directors. Example initiatives for addressing structural factors include developing screening forms to identify mental health conditions and revising HCPs’ job descriptions to highlight their responsibilities in identifying and assessing mental health conditions. Other changes may include reforming PHC policies to include anti-stigma and confidentiality provisions as well as clinical and administrative mental health protocols. In addition, directors should also consider incentives for PHC staff. It is also important to ensure adequate infrastructure, such as the provision of secure storage of patient files for confidentiality and private rooms for consultation. Moreover, it is important to address the wellbeing of staff and provide self-care, since high stress levels can lead to burnout of HCPs [50]. Professional burnout has long been used as an explanation for stigmatisation in mental health care, and components of burnout, such as high emotional exhaustion and feelings of low personal accomplishment, have been shown to be significantly associated with negative attitudes toward mental health patients [9]. Ultimately, especially given the impact that COVID-19 had on mental health services, it is crucial to consider telemental health services as well as mobile-based intervention such as Step-by-Step, an e-mental health intervention by WHO and NMHP that was perceived to be relevant and acceptable [51]. In future research, it is important to evaluate whether newly implemented strategies, such as Step by Step, reduces stigma perceived by patients with MHC.

The establishment of the NMHP in 2014 and the launch of the first national strategy for mental health in 2015 [52] to reform the mental health system and scale up services have significantly expedited the provision of mental healthcare in PHCs. Although many changes have been enacted at the structural level of the health system in Lebanon [19], the total expenditure on mental health from the MoPH’s budget remains very minimal, and is mainly allocated for long-stay inpatient costs in mental hospitals [18, 53]. With the country facing economic collapse and political turmoil, funding challenges continue to inhibit the provision of adequate resources and training programmes, as well as interrupt the support and supervision provided by MHPs to HCPs.

Strengths and limitations of the paper

This study included several trends within mental health that were previously understudied. To our knowledge, this is the first qualitative study in a PHC setting in Lebanon where SUs, along with a wide range of other stakeholders (n = 45), were interviewed about mental health-related stigma. Whereas in previous research the contribution of SUs had been ignored [4], in this study there was a relatively significant number of SUs (n = 14) which constituted around 30% of the total interviews. Furthermore, this study offered the ability to triangulate findings across a wide range of stakeholders and the capability to analyse results in a comprehensive approach. In addition, having variety and heterogeneity within the SUs sample enriched the study content and informed us of the diverse, heterogeneous perception of stigma and barriers related to the Lebanese context, since it included respondents who varied by gender, and nationality. Additionally, the present study also addressed structural stigma, which has not been studied in relation to stigma among primary care staff. An additional strength is that our qualitative approach allowed for an exploration of specific contexts and cultural indications of stigma which have not been studied previously. In reference to Evans-Lacko et al. [54], only 11% of previous studies on stigma selected a qualitative methodology, of which a majority lack a concise definition of stigma.

The study is not without its limitations. Firstly, it was conducted among four PHC centres in the Beirut and Mount Lebanon governorates only, for convenience of these areas, whereas other more underprivileged areas (such as North Lebanon, South Lebanon, Bekaa and rural areas) should be further explored in the future and may reflect other important outcomes. Another limitation is that SUs interview sample did not include people with severe mental illness, as in general, PHC centres are expected to treat people with less severe illness, nevertheless it is the case that occasionally PHC staff are asked to see people with severe mental illness due to their emergent nature. Furthermore, most of our findings rely on self-reports from PHC staff. Contact with most staff members (front liners, social workers, nurses & GPs) were exclusively established through their supervisors. SUs were also reached by contacting PHC centres focal points, who then referred SUs to the research team for interviews. This outreaching technique might have impacted the results due to responder bias. Although every effort was made to ensure confidentiality and assure SUs that their statements would not affect their treatment, the fear of losing services might still have affected some participants’ responses. A more direct sampling technique without going through the PHC centres may have reduced the risk of this bias occurring. Another aspect that would impact results is the possibility of social desirability bias and the attempt of interviewees to avoid painting themselves in an unfavourable light. Furthermore, previous collaborations and relations between the NMHP and PHC service providers may have reinforced the effect of social desirability. Finally, this study portrayed a period before Lebanon’s intersecting crises, including its economic crisis, COVID-19 epidemic, political unrest, and the Beirut port blast, which had a significant impact on many sectors, including healthcare and mental health services in the country. As a result, the situation presently may now differ from that which existed prior to 2019.

Implications of the findings

This study may inform future interventions at the primary care level and will inform mental health training programmes. It also provides qualitative findings that support the framework for bridging the mental health treatment gap at PHC centres, and in turn improving the integration of mental health services into primary care. Future activities and further analysis of the interviews can also be used to explore facilitators and barriers to integrating mental health into primary care and suggest interventions that can support this integration. In future research, ethnographic and direct observational data within PHC settings can complement interview findings. Furthermore, combining qualitative with quantitative methods may be useful for better understanding stigma and reaching a larger sample, which could be compared to studies within other settings in the MENA region and worldwide. In addition, more detailed information about the interaction between different types of stigma within various levels in a health system may shed light on the root causes of our findings. Future studies should examine the cultural and contextual factors informing stigma in primary care with larger study samples and in different areas to develop specific guidelines for cultural adaptations [55]. These findings can be used to inform adaptations of strategies to reduce MHC stigma among HCPs [5].

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