Health Service Research Department, Institute of Psychiatry, London
Rethink Severe Mental Illness, London
Health Service Research Department, Institute of Psychiatry, London
Correspondence: Dr Vanessa Pinfold, Section of Community Psychiatry (PRiSM), Health Service Research Department, Institute of Psychiatry, De Crespigny Park, Denmark Hill, London SE5 8AF, UK. e-mail:v.pinfold{at}iop.kcl.ac.uk
Declaration of interest The study was funded by an educational grant from Lundbeck UK.
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ABSTRACT |
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Aims To assess the effectiveness of an intervention with young people aimed at increasing mental health literacy and challenging negative stereotypes associated with severe mental illness.
Method A total of 472 secondary school students attended two mental health awareness workshops and completed pre- and post-questionnaires detailing knowledge, attitudes and behavioural intentions.
Results Young people use an extensive vocabulary of 270 different words and phrases to describe people with mental health problems: most were derogatory terms. Mean positive attitude scores rose significantly from 1.2 at baseline to 2.8 at 1-week follow-up and 2.3 at a 6-month follow-up. Changes were most marked for female students and those reporting personal contact with people with mental illness.
Conclusions Short educational workshops can produce positive changes in participants' reported attitudes towards people with mental health problems.
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INTRODUCTION |
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METHOD |
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Phase I mental health awareness work-shops were delivered by a facilitator who worked in the field of mental health. The first hour-long session concentrated on pupils' understanding of mental health and mental illness, including the viewing of a short video about people living with depression and schizophrenia. The second session concentrated on promoting a positive sense of well-being and challenging the use of stereotypical labels such as nutter, loony, mental and psycho, language known to dominate young people's descriptions of mental illness (Weiss, 1994; Bailey, 1999). A non-medicalised approach was adopted, with emphasis placed on removing the distance between us and them rather than exploring a medical disease paradigm. The lesson plans were designed around a series of group exercises. The workshops were supported by information leaflets produced specifically for young people.
In phase II, sessions were co-facilitated by a person who had personal experiences of living with mental health problems. Phase I lesson plans were used but, in addition, personal experiences were shared sensitively with students through a short talk followed by a question-and-answer session. No control schools were involved in the pilot programme.
The evaluation
Pupils completed a pre-test questionnaire at the start of the first session
and a follow-up assessment 1 week after attending the second session. Pupils
in phase I schools also completed a 6-month follow-up assessment. The
questionnaires were based on an instrument piloted in the World Psychiatric
Association's anti-stigma schools project in Canada
(World Psychiatric Association,
2000) and included: four factual statements (e.g. one in four
people will develop mental health problems over the course of their lives) and
five attitude statements (e.g. people with mental health problems are
unpredictable), all rated agree, disagree,
unsure, and four social distance rating scales rated
definitely, probably, probably not,
definitely not and not known (e.g. I would be
afraid to talk to someone with mental health problems). Social distance scales
are used as proxy indicators of planned reported behaviour. The factual
statements tested student recall of information provided to them in the
workshops. An aggregate attitude score was created by totalling the five
individual items. Pre-tests included an open-ended question asking for
descriptions of people with mental health problems, and the follow-up surveys
asked students to provide assessment ratings for the overall programme.
Limited socio-demographic data and a rating to indicate personal experience
through knowing someone with mental health problems (termed personal contact)
were also collected. The questionnaire was a pilot instrument.
Quantitative data for the study were analysed using the SPSS (version 10) for Windows. Paired t-tests compared the differences between baseline and follow-up attitude scores. In this exploratory study we have compared mid-point to baseline and final follow-up to baseline separately when comparing student views over time. Analysis of variance was used to estimate the relationship between general attitude scores and respondent characteristics. Qualitative data were coded using basic content analysis. These data were coded twice by one researcher (V.P.) and once by another member of the research team (H.T.) to identify emergent themes.
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RESULTS |
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Sample characteristics
The sample was predominantly female (73%), 208 students (44%) reported that
they personally knew someone with generalised mental health problems and 182
students (39%) attended a workshop including a personal experience talk.
Fifty-two per cent of the sample attended the coeducational schools and 48%
attended the girls' grammar schools.
The linguistic landscape
Young people use an extensive vocabulary of terms to describe mental ill
health. As shown in Table 1,
the sample applied 270 different words or short phrases to describe a person
with a mental health problem. Although the majority were derogatory terms, a
quarter of pupils applied only sensitive descriptions focusing upon people's
emotions and positive characteristics:
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I would call them different but I wouldn't mind it. I would just feel strange, I definitely wouldn't say anything to hurt them or make them feel worse than they already are.
I wouldn't call them anything because it can mean all sorts of different problems.
Mental illnesses are problems that they might not think they can overcome.
Few mental health descriptions related to emotional well-being, although young people do relate both mental health and mental illness with emotion states. When students were asked in the 6-month follow-up what they most remembered about the sessions, 37% noted the exercises that addressed language used to describe mental health problems, compared with 15% who remembered the video that was shown.
Changes in student views
Student responses to five attitude statements are shown in
Table 2. When composite
attitude scores were compared (range -5 to +5), mean scores rose from 1.2
(s.d.=1.8) at baseline to 2.8 (s.d.=1.9) at the 1-week follow-up
(t=-16.4, P<0.0001). At the 6-month follow-up the mean
score had fallen to 2.3 (s.d.=1.9), although this was still significantly
higher than the score at baseline (t=-8.5, P<0.0001).
Analysis of variance was used to estimate the relationship between composite
attitude scores (dependent variable) and sample characteristics. Attending
grammar school and personal contact were associated independently with a
higher baseline attitude score, but this model was poor at predicting
individual baseline scores (R2=7%). Baseline attitude
score, being female, personal contact and attending grammar school were
associated independently with a positive change in attitude scores between
baseline and the 1-week follow-up (R2=31%). At the 6-month
follow-up, baseline attitude scores and personal contact were associated
independently with a positive change (R2=11%).
Seventy-three per cent of students self-rated their attitudes as more positive
towards people with mental health problems immediately after attending the
workshop sessions and 61% retained a positive self-rating at 6-month
follow-up.
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Changes in social distance ratings
The cumulative proportion of students expressing no social distance across
four items changed marginally over time: baseline, 32 students (8%,
n=421); 1-week follow-up, 58 students (13%, n=434); 6 month
follow-up, 24 students (11%, n=207). Across individual social
distance items, reported social distance did not change significantly in the
post-intervention follow-ups except for students reporting that they were less
afraid to talk to someone with a mental health problem at the 1-week follow-up
(32%) than at baseline (22%): t=5.98, P<0.0001. Analysis
of variance identifies that baseline social distance scores and the inclusion
of a personal experience talk within the programme are two variables
associated independently with a reduction in social distance at the 1-week
follow-up (R2=34%). The impact of a personal experience
talk was not assessed at the 6-month follow-up because phase II schools were
not re-assessed at 6 months.
Impact on mental health literacy
At baseline only six students (1%) provided correct ratings for all four
factual statements. Significant changes in these ratings were recorded at the
1-week post-intervention follow-up, as shown in
Table 3, but the 6-month
follow-up data indicated that factual recall changes may not be long-lasting.
At the 1-week follow-up, 24% of students provided correct ratings for all four
factual statements, but this proportion fell to 6% after 6 months.
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Effect of individual characteristics on student views
To explore the impact of education on public attitudes, we compared the
responses from coeducation female students (n=118) and students at
the girls' grammar schools (n=221). The grammar school students
reported significantly higher (and thus more-positive) factual and attitude
scores at all three data collection points. Mean attitude scores for females
in the coeducational schools increased from 1.0 to 2.6 between baseline and
the 1-week follow-up, and for the girls' grammar school students the increase
was similar (mean 1.7-3.4). The difference between coeducation and girls'
grammar school increases in factual recall scores were more marked:
coeducation, from -0.4 to 1.3; girls' grammar school, from 0.4 to 2.8.
To explore the relationship between gender and opinions of people with
mental health problems, a comparison between male (n=122) and female
(n=118) responses in coeducation schools was carried out. At baseline
there were no significant differences between male and female coeducation
factual, attitude or social distance rating scores, but a higher proportion of
female students in coeducational schools reported different views at follow-up
compared with their male colleagues. In particular, female coeducation
students were more likely than male colleagues to rate that people with mental
health problems were not difficult to talk to at the 1-week follow-up (61%
females compared with 48% males, 2=4.34, P=0.03) and
6-month follow-up (58% v. 39%,
2=4.4,
P=0.03), not to blame for their mental health difficulties (1-week
follow-up: 91% v. 77%,
2=9.2, P=0.002;
6-month follow-up: 94% v. 83%,
2=3.2,
P=0.05) and would not be upset or embarrassed to be in the same class
as someone with mental health problems (1-week follow-up: 61% v. 43%,
2=4.0, P=0.04; 6-month follow-up: 67% v.
49%,
2=4.0, P=0.04).
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DISCUSSION |
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Unsurprisingly, some popular stereotypes surrounding mental illness are easier to challenge than others because interventions must work against powerful providers of misinformation such as the media. Studies highlight how, through films (Wahl & Lefkowits, 1989), newspaper reports (Philo, 1996) and television programmes (Wilson et al, 2000), people with mental health problems are represented in stereotypical roles and a pejorative language against difference is normalised through crazy, out of control, loony characters. Overall, the workshops did not have an impact on the them and us phenomenon because few changes in social distance ratings were reported. It will take more than two short educational workshops to address young people's deep-rooted beliefs and fears about interacting with people with severe mental illness. However, introducing the subject of mental illness alongside a personal, social, health and education teaching programme that focused upon other important social and health issues, such as friendship and bullying, healthy eating and contraception, should ensure that mental health problems are recognised as a central health concern for young people to understand and self-manage.
Promoting personal contact
The study assessed the importance of experiential learning as a teaching
strategy to reduce psychiatric stigma and discrimination. This was, in part, a
response to student demands to improve the sessions by introducing a speaker
to discuss personal experiences of living with depression or schizophrenia.
Guarding against the use of tokenism, the programme responded by training
co-facilitators for phase II of the study and the inclusion of personal
experience talks did have an impact on social distance scores. Personal
contact was particularly important in affecting attitude scores, suggesting
that students who know someone with mental health problems learnt more from
the sessions than those who did not associate the subject area with a personal
contact. Anti-discrimination work undoubtedly benefits from collaborative
partnerships in the planning and delivery of mental health education sessions,
and future studies should develop the co-facilitation strategy. The
empowerment of mental health consumers may be promoted through mental health
education projects, and thus consumer involvement may have a positive impact
on both the learning experiences of young people and the mental health of
consumer facilitators. Further research is needed to establish a best-practice
teaching model for mental health, comparing teacher-led and
expert-led interventions.
Study limitations
The study had several limiting factors. Working within pragmatic
constraints, the project team delivered a short educational intervention that
was evaluated using a brief self-report survey. It is important to acknowledge
the limitations of pen-and-paper assessments for capturing attitude and
knowledge changes, behavioural responses and the impact of potential social
desirability bias. The study was a small uncontrolled intervention and thus
the findings are weakened by the lack of any control group. Although the
measured changes in student opinions are likely to be the result of the
workshop interventions, this conclusion may only be inferred. Response rates
were moderate.
The agenda for mental health education in schools
The strains placed on the emotional well-being of young people in modern
society have been well documented (Mental
Health Foundation, 1999) and the rate of suicide among young
people, particularly young men, is a growing concern. Despite the prevalence
of mental illness, the majority of young people experiencing emotional
problems do not consult their general practitioner
(Potts et al, 2001).
Young people, therefore, have been the focus of several mental health
awareness pilot schemes, including a community mental health programme in
Rawalpindi, Pakistan (Rahman et
al, 1998), and the Mindmatters programme in
Australia (Wyn et al,
2000). A UK population formally uneducated on issues related to
mental health and mental illness is sustained by an education system that does
not include emotional health as a core part of the national curriculum, not
even in the personal, social, health and education programme. Ideally, a short
educational programme addressing psychiatric stigma and discrimination should
be part of a whole-school strategy supporting the emotional well-being of
young people and school staff. Stigma-reducing interventions would be part of
a compulsory mental health promotion strategy that extends through the school
curriculum year on year, addressing social values, health and social
well-being and the development of social skills to promote socially
responsible behaviour. The introduction of compulsory citizenship
classes in the curriculum in the UK from September 2002 may assist this
important agenda.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication July 9, 2002. Revision received November 19, 2002. Accepted for publication December 3, 2002.
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