Mental illness related stigma can lead to low rates of seeking help, lack of access to care, under-treatment , and social marginalization . Ultimately this leads to the inability of a person with mental illness to recover. Recovery is a process which occurs when people with mental illness discover, or rediscover, their strengths and abilities for pursuing personal goals and develop a sense of identity that allows them to grow beyond their mental illness [3, 4].
Studies have varied in the dimensions of stigma examined, but the most common ones are: ‘perceived stigma’, which refers to one’s belief that others perceive an individual as socially unacceptable [4–7] and ‘self-stigma’, which refers to a similar, internalized perception of oneself leading to the fear of seeking help or disclosing one’s mental illness due to the stigma associated with mental illness . Other dimensions of stigma that have been examined include social distance, which refers to one’s desire to maintain distance from people with mental illness [5, 9], ‘dangerousness”, which refers to one’s belief that the individual is dangerous , recovery, which refers to one’s belief that people with mental illness can recover . Emotional reactions  such as a lack of social responsibility as well as a lack of empathy or compassion towards people with mental illness are also dimensions of stigma . While some may consider that compassion and social responsibility may be paternalistic and stigmatizing towards people with mental illness , these dimensions can be seen as important indicators of non-stigmatizing attitudes and are acknowledged widely as significant competencies of health care providers [4, 12].
Evidence for an association between various dimensions of stigma is either lacking or largely inconsistent. For example, perceived stigma has been found to be unrelated to help seeking in some studies [13, 14]. It must also be noted that most of the models that currently describe the dimensions related to mental illness stigma are based on individual-level rather than a sociological-level of structural indicators of stigma which can occur at the institutional or government level. For the purposes of this paper, we will focus on individual-level of stigma, specifically by health care providers.
Stigma has been criticized as being too vaguely defined and individually focused  and thus existing models have defined stigma as a dynamic interrelationship of components. This interrelationship involves cognitive, affective and behavioural components. In order to understand and measure stigma it is important to conceptualize the term within a more detailed model.
A model by Link and Phelan which has been widely used in the literature describes mental illness stigma as four components which are: labelling, stereotyping, separating and status loss/discrimination. Throughout these components, it has been suggested that emotional reactions can occur . There are three cognitive processes; labelling begins when personal characteristics are signalled to show an important difference between the person who stigmatises and the stigmatised. Stereotyping then occurs when the labelled differences are associated with undesirable characteristics. This is followed by categorically distinguishing or separating between the mainstream group and the labelled group, perceiving the labelled group as fundamentally different. Ultimately, the labelled group is then devalued, rejected and excluded through the process of status loss or discrimination .
Another model by Corrigan, contains the components of stereotype, prejudice and discrimination that are seen as causally related. For example, a person who believes (cognition) a person with mental illness is dangerous (stereotype) might negatively evaluate or fear (affect) the person with mental illness as dangerous, leading to prejudice. This would then lead to discrimination (behaviour) when the person is treated inappropriately for their mental illness by receiving sub-standard care .
What can be drawn from these models so far is that they have commonly embedded within them the cognitive, affective and behavioural components. While they are useful in describing mental illness related stigma as a social psychological phenomenon, they may not be valid or useful for measuring outcomes in mental health promotion and health education interventions aimed to reduce the stigma of mental illness.
A final conceptualization of stigma is the tri-partite model, which proposes that stigma is an overarching term including three core elements: knowledge (misinformation/differences in understanding due to culture or religion), attitudes (prejudice) and behaviour (discrimination) . The knowledge, attitudes and behaviour framework allows clear intervention targets and units of measurement [17, 18]. The importance of knowledge, attitudes and behaviour has been established in medical education with medical students, nurses, and other health care providers [17–20]. The knowledge, attitudes and behaviour framework is also one that is widely used in health promotion [21, 22]. Similar to the Corrigan model, the tri-partite model focuses on the problem of attitudes in the form of prejudice which can be elicited as common stereotypes or emotional reactions rather than separating them like the previous models. The tri-partite model is adaptable in that it allows for attitudes towards people with mental illness to be comprised of the various dimensions of stigma .
In the literature, it has been shown that attitudes towards people with mental illness can be measured using stereotypes such as: ‘people with mental illness are dangerous,’ and ‘people with mental illness do not recover’ [23, 24] as well as a desire for social distance because of the aforementioned stereotypes . Stigmatizing attitudes can also be measured in the form of emotional reactions towards people with mental illness. Finally, disclosing that one has a mental illness, because of the dimensions described above, can lead to self stigma and may also be an indicator of mental illness related stigma [24, 25]. While it has been shown that self stigma is different than holding stigmatizing attitudes towards people with mental illness , we believed it was important to measure in health care providers because, we saw disclosure as a dimension of stigma that would also indicate whether the respondent held stigmatizing attitudes towards mental illness. For example, those who would disclose that they had a mental illness may not think that mental illness is something to be ashamed of and may therefore be less stigmatizing. This has been described in the literature where some refuse to be diminished by stigma and becoming more active participants of change in health care . Also, potential users of the instrument, such as professional organizations, are likely to be interested in the issue of disclosure because of a desire to see their members receive appropriate treatment and support for mental health issues.
Through extensive review of the academic literature on surveys used to measure attitudes towards people with mental illness, a large gap was shown in the area of surveys used to measure the attitudes of health care providers . A new measure of stigma intended for healthcare providers is pertinent because stigma among health care providers differs from other kinds of stigmas held by various other groups. For example, it has been reported that people with mental illness have poorer physical health in part because medical professionals wrongly associate the physical symptoms experienced by the person with mental illness to the mental illness itself [27–30]. This could be due to a phenomenon called ‘diagnostic overshadowing’ [17, 30].
Diagnostic overshadowing can be defined as the process by which the physical problems of a patient are over-shadowed by their psychiatric diagnosis [17, 30]. It is important to note that diagnostic overshadowing is not unique to primary care and may occur in other areas of health services [17, 26]. An investigation of the physical healthcare of patients with schizophrenia in primary care  showed that people with schizophrenia were no more likely than the general population to be targeted for physical health checks despite increased physical health risks. Furthermore, people with schizophrenia were significantly less likely to receive important basic health checks such as blood pressure and cholesterol measurement .
Medical practitioners also diagnose and treat people with mental illness differently. For example, people with mental illness are “substantially less likely to undergo coronary re-vascularisation procedures” compared to people without mental illness . Similarly, people with co-morbid mental illness and diabetes are less likely to be admitted to hospital for diabetic complications than those with no mental illness .
Furthermore, people with mental illness may have less access to medical care [34, 35] such as obtaining a primary care physician [34, 35] as there is a need for community mental health centres to address barriers to primary medical care . People with mental illness may also feel unwelcome in certain medical settings because of staff attitudes [36–42].
Although health care providers are thought to hold attitudes that are positive, compassionate and encouraging towards people with mental illness, this is often not the case. Health care providers may be ignorant about the possible outcomes of people with mental illness. Often this may be due to inadequate training . It has been reported that 68% of the mental health professionals surveyed thought that most clinicians do not receive appropriate training in dealing with people with severe mental illness .
A large body of research on the attitudes of health care providers has repeatedly shown negative attitudes towards people with mental illness. This has been a problem and continues to be a problem in primary care, mental health services and within the education of health care providers [37–42].
As part of its 10-year mandate, The Mental Health Commission of Canada (MHCC) has embarked on an anti-stigma initiative called Opening Minds (OM) to change the attitudes and behaviours of Canadian health care providers towards people with a mental illness. OM is the largest systematic effort undertaken in Canadian history to reduce the stigma and discrimination associated with mental illness. OM’s philosophy is to build on the strengths of existing programs from across the county, and to scientifically evaluate their effectiveness. A key component of programs being evaluated is contact-based educational sessions, where target audiences hear personal stories from and interact with individuals who have experience with mental illness and have recovered or are managing their illness. OM’s goal is to replicate effective programs nationally, develop new interventions to address gaps in existing programs and add other target groups over time. (http://www.mentalhealthcommission.ca/English/Pages/OpeningMinds.aspx)
Evaluation describes and explains the practice of participants to determine their effectiveness [43, 44]. Because evidence-based educational interventions are given priority, evaluation drives undergraduate, post graduate and continuing education curriculum development . In order to achieve its goal with healthcare providers, the Opening Minds initiative required a current, reliable and valid tool to evaluate best practices to reduce the stigma of people with mental illness. Many of the evaluative tools that exist today are not adequate for our purpose because they do not relate specifically to the role of the health care provider.
The aim of this study was to develop, and test the Opening Minds Scale for Healthcare Providers (OMS-HC).