Stigma against persons with mental illness by health care providers contributes to lack of delivery of evidence-based care, long duration of untreated mental illness before initiation of care, and lack of appropriate medical care for persons with mental illness. This is compounded by structural stigma within health systems, which is exemplified by policies and practices that fail to meet needs for mental health budgets, psychiatric supervision of primary care providers, and physical infrastructure for safe and effective care. The purpose of our proposed research is to address the vital need for development of intervention packages to address provider stigma and structural stigma, with a focus on psychotic disorders. The rationale for conducting this study in low-and-middle income countries (LMIC) is because these regions demonstrate the greatest dearth of evidence-based services, and there is a lack of research on how to reduce stigma in a manner that improves patient clinical outcomes in low resource settings. Our goal is to develop an intervention package for Optimizing Provider Attitudes and competence in Learning mental health systems (OPAL). Drawing on the evidence base for addressing provider stigma, OPAL will include facilitated social contact between providers and persons with mental illness. For structural stigma, learning health systems will serve as a model to improve attitudes and clinical care through patient engagement in service design, enhanced provider access to systems data, and promotion of team-based health system administration. To accomplish the objective of developing the OPAL package to reduce provider and structural stigma, we will undertake three aims: 1. develop a draft intervention package through qualitative research including a stakeholder analysis of the package and a pilot training of trainers for consumers, 2. adapt and develop measures to evaluate the package, and 3. strengthen capacity for implementation science in LMIC. This proposed research will take place in Ethiopia and Nepal. These African and Asian settings exemplify LMIC mental health service needs and are participating in implementation research through Emerging Mental Health Systems in Low and Middle Income Countries (EMERALD) and Programme for Improved Mental Health Care (PRIME), which employ the World Health Organization's (WHO) mental health Global Action Programme (mhGAP).

The impact of successful completion of our research aims will be (1) an intervention package that can be added to mhGAP and piloted by WHO, and (2) intervention content and measures to apply for funding to conduct effectiveness trials to evaluate improving provider attitudes and competence as mechanisms to improve patient outcomes.