Improving Mental Health Literacy: A Review of The Literature

Improving Mental Health Literacy: A
Review of the Literature

June 2002

Catherine Francis, Jane Pirkis, David Dunt
Centre for Health Program Evaluation, The University of
Melbourne

R. Warwick Blood
School of Professional Communication, The University of
Canberra

Cathy Davis
School of Social Work, Australian Catholic University
Signadou Campus, Canberra

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Table of Contents
EXECUTIVE SUMMARY 4
INTRODUCTION 4
PURPOSE OF THE REVIEW 4
RESEARCH QUESTION 4
METHOD 4
REVIEW OF INDIVIDUAL STUDIES 5
HEALTH COMMUNICATION CAMPAIGNS 6
CONCLUSIONS 7
1. INTRODUCTION 8
MENTAL HEALTH LITERACY 8
PURPOSE OF THE REVIEW 9
RESEARCH QUESTION 9
METHOD 10
2. REVIEW OF INDIVIDUAL STUDIES - WHOLE OF COMMUNITY
PROGRAMS 13
MASS MEDIA CAMPAIGNS 13
OTHER MODES OF DELIVERY 20
METHODOLOGICAL ISSUES 23
SUMMARY 25
3. REVIEW OF INDIVIDUAL STUDIES - PROGRAMS TARGETED TO
SPECIFIC POPULATIONS 34
CARERS AND FAMILIES OF PEOPLE WITH MENTAL ILLNESS 34
SCHOOL-BASED PROGRAMS FOR ADOLESCENTS 41
PEOPLE FROM NON-ENGLISH SPEAKING BACKGROUNDS 46
SUMMARY 50
4. HEALTH COMMUNICATION CAMPAIGNS 64
OVERVIEW OF THE COMMUNICATION CAMPAIGN LITERATURE 64
ADVERTISING AND COMMUNICATION CAMPAIGNS 69
ANALYSIS OF THE COMMUNICATION CAMPAIGN LITERATURE 72
SUMMARY 79
5. CONCLUSIONS 81
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RESEARCH QUESTION 81
APPENDIX 1 PREVIOUS REVIEWS OF THE LITERATURE 93
REVIEWS OF MENTAL HEALTH LITERACY PROGRAMS 93
REVIEWS OF COMMUNICATION CAMPAIGNS 96
REFERENCES 110
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Executive Summary
Introduction
The National Mental Health Strategy has a strong emphasis on mental health
promotion and mental illness prevention. The Second National Mental Health Plan
aims to build on the work of the first five years of the Strategy by focusing on the
mental health literacy of key groups in key settings (Australian Health Ministers
1998; 1999).

The term mental health literacy was coined by J orm et al (1997) as an extension of
the concept of health literacy. It may be defined as knowledge and beliefs about
mental disorders which aid their recognition, management or prevention. It includes:
the ability to recognise specific disorders; knowing how to seek mental health
information; knowledge of risk factors and causes, of self-treatments and of
professional help available; and attitudes that promote recognition and appropriate
help-seeking.

Activities designed to improve mental health literacy are a significant component of
mental health promotion. Strategies for improving mental health literacy generally
comprise education and communication approaches. These activities may be
classified in a number of different ways, and can be considered in terms of scope,
mode of delivery, scale, and setting.

Recent studies of mental health literacy in Australia have shown that the public are
not very well informed about mental illness. It is important that the level of mental
health literacy in the population be improved in order for individuals to recognise
mental illness and manage their own mental health more effectively. Improving
overall mental health literacy is also important in terms of overcoming stigma
associated with mental illness.
Purpose of the review
The aim of this literature review is to evaluate and interpret current research relating
to improving mental health literacy, in order to identify the most effective
communication strategies and tools to improve mental health literacy among target
audiences in the Australian population. The review involves a systematic examination
of the available research. In addition, this report provides an overview of the literature
relating to public health information campaigns.
Research question
What are the most effective communication strategies and tools to improve mental
health literacy among target audiences in the Australian population?
Method
Literature relating to mental health literacy programs was identified through a number
of database searches using relevant search terms. Appropriate databases were
searched for English language articles dated from 1980 to May 2002. The databases
searched included: Medline, PsychINFO, Current Contents, Communication
Abstracts, Cochrane Database of Systematic Reviews, EMB Reviews, York Database
5
of Abstracts of Reviews of Effectiveness, and ProQuest. In addition to database
searches, efforts were made to uncover unpublished work of relevance to the literature
review.

The relevant literature involving programs to improve mental health literacy was
identified and classified according to the following general categories:

Whole of community programs
Programs targeted to specific populations

Information relevant to the effectiveness of individual programs was extracted from
each of the studies. The methodological issues and limitations of each study were also
examined, in order to determine the validity and importance of any findings. The data
extracted from the studies were drawn together in order to provide a descriptive
review of the effectiveness of different programs to improve mental health literacy.
Review of individual studies
A range of programs identified for inclusion in this review addressed the issue of
improving mental health literacy at a whole of community level. Most of these
programs involved mass media campaigns, however a small number of studies used
other modes of delivery, such as education courses. In addition to whole of
community programs, a number of studies were identified which provided evaluations
of programs directed towards specific subgroups of the population.
Previous reviews of mental health literacy campaigns in the mass media have
indicated that there is potential for such programs to have an impact on community
attitudes, knowledge and behavioural intentions. Despite important methodological
limitations, the literature included in this review also indicates that mass media
campaigns can have a positive impact on levels of mental health literacy in the
population. Evaluations of programs conducted at national and statewide levels
generally indicated that attitudes and knowledge improved; however the extent of
changes was acknowledged to be limited. While it may be concluded that mass media
campaigns are a potentially effective approach to improving mental health literacy, it
should be acknowledged that such strategies are generally expensive, and none of the
studies adequately addressed the issue of cost-effectiveness.

Studies of modes of delivery other than mass media were not common, and were less
conclusive about changes in knowledge, attitudes and behaviour. There were,
however, indications that social contact with people experiencing mental illness may
be associated with improved community attitudes.

A number of recommendations may be made about the content and mode of delivery
of campaigns targeted to the whole of the community. Importantly, evaluations of
other health communication campaigns conducted in Australia and overseas have
found that messages are particularly well received when the positive outcomes of
attitudes or behaviours are communicated. With respect to mode of delivery, the
literature indicates that mass media campaigns may be most effective when
complemented by other more direct approaches, such as the dissemination of printed
materials or community activities.
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The literature suggests that programs targeted to specific groups within the population
can improve levels of mental health literacy. It is important to note, however, that
there were significant methodological limitations associated with many of the studies
reviewed in this section, and the generalisability of the findings is limited. The
strongest evidence relates to the impact of educational interventions for families of
people with schizophrenia, and the literature indicates that programs targeted to carers
and families of people with mental illness may also result in improved outcomes for
mental health consumers. Evaluations of school-based programs targeted to
adolescents also indicated positive effects in terms of awareness and attitudes relating
to mental health issues.

Given the nature of the literature, it is clear that there is a need for further evaluations
of programs targeted to subgroups of the population, particularly in the Australian
context. It is recognised that there are various groups within the community who may
benefit from targeted mental health literacy programs, however there is little literature
addressing the issue of effectiveness of such programs at present.
Health communication campaigns
In contrast to the relatively limited amount of literature addressing mental health
literacy programs, there is a vast literature relating to public health information
campaigns. There is evidence that communication campaigns can be effective under
certain conditions for particular audiences, although evaluations of previous
communication campaigns suggest many failures and unrealistic expectations about
possible outcomes. The role of mass media campaigns in particular is likely to be in
creating awareness and knowledge of a campaign message rather than achieving
behavioural changes. It is acknowledged that mass media messages alone usually
achieve little, and therefore other supportive interventions are necessary.

In order for a communication campaign to be successful, a number of components are
considered essential. Message development is an integral component of the campaign,
and there should be widespread exposure to campaign messages. Campaign appeals
that are socially distant from audiences are generally ineffective, and messages
promoting prevention are less likely to be successful than those with immediate
positive consequences. Research should focus not only on summative evaluation,
which measures campaign outcomes, but also formative evaluation, which focuses on
campaign planning, and process evaluation, to monitor campaign implementation.

Contemporary communication campaigns are likely to recognise the capacity of
audiences to make meaning out of campaign messages, to misinterpret messages, or
even to resist messages. This model moves away from reliance on the knowledge
attitudebehaviour paradigm that underpins most of the earlier communication
campaigns and the traditional media effects theory. The newer approach to
communication campaigns acknowledges the importance of investigating the factors
that various audiences bring to their understanding and reception of communication
campaign messages.
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Conclusions
There is evidence that mass media campaigns designed to reach the general public can
achieve positive outcomes in terms of mental health literacy. Research also indicates
that campaigns are particularly effective when they involve more than one form of
media, and include community-based components and/or direct interventions. It is,
however, important to note that the impact of such campaigns is limited. Mental
health literacy programs that target the general public but do not involve mass media
approaches appear to be less common, but show some evidence of effectiveness in
terms of attitude change. Importantly, studies of such programs have found that direct
contact with individuals with mental illness is associated with the development of
more positive attitudes.

With respect to programs targeting specific audiences, there is evidence that school-
based programs can improve mental health literacy among adolescents. It should be
noted that important methodological issues emerged in a number of studies focusing
on school-based mental health literacy programs, particularly those conducted in
Australia, which prevent firm conclusions being drawn. Some of the strongest
evidence of effectiveness of mental health literacy programs comes from studies of
educational interventions for carers and family members of people with mental
illness. In particular, programs for family members of individuals with schizophrenia
have been evaluated in a number of studies and found positive results in terms of
improvements in knowledge and attitudes.

When considering the evidence of effectiveness of health communication programs, it
is clearly important to bear in mind the theoretical basis for communication strategies.
It is apparent from the literature, however, that the majority of studies of mental
health literacy programs do not adequately address theoretical issues. Research into
mental health literacy campaigns should take into account how various audiences
acquire health knowledge and what factors motivate audiences to attend to public
health messages.

Most of the programs studied were conducted in countries other than Australia. It is
therefore difficult to determine to what extent successful programs may achieve the
same effects in the Australian context. In addition, significant methodological issues
emerged in a number of these studies, particularly those investigating school-based
programs, and the strongest evidence tends to come from evaluations of overseas
studies. There is a clear need for evaluation of mental health literacy programs in
Australia, both in terms of campaigns targeted to the general population, and those
aimed at particular sub-groups.

The issue of cost-effectiveness has not been addressed adequately in previous studies
of mental health literacy campaigns. This is clearly a key area for further research,
particularly as many programs tend to involve high cost strategies such as mass media
campaigns. In addition, much of the previous research has focused only on evaluation
of outcomes, and has tended to neglect evaluation of the development and
implementation phases of communication and information programs. It is important
that future research involves appropriate resources and methods to achieve useful
evaluation of strategies to improve mental health literacy.
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1. Introduction

The National Mental Health Strategy has a strong emphasis on mental health
promotion and mental illness prevention. During the first five years of the Strategy,
promotion and prevention efforts focused on raising community awareness of the
prevalence of mental illness (Australian Health Ministers 1992a; 1992b). The Second
National Mental Health Plan aims to build on this work by focusing on the mental
health literacy of key groups in key settings (Australian Health Ministers 1998; 1999).

Mental health literacy
The term mental health literacy originated as an extension of the concept of health
literacy (J orm et al 1997). Nutbeam (2000) notes that health literacy has been
referred to in the health literature for at least 30 years. Health literacy is recognised as
an important aspect of health promotion, and may be defined as the personal,
cognitive and social skills which determine the ability of individuals to gain access to,
understand, and use information to promote and maintain good health (Nutbeam,
2000).

In contrast, a focus on mental health literacy has been neglected. The term mental
health literacy was coined by J orm et al (1997), who used it to describe knowledge
and beliefs about mental disorders, which aid their recognition, management or
prevention. It includes:
the ability to recognise specific disorders;
knowing how to seek mental health information;
knowledge of risk factors and causes, of self-treatments and of professional
help available; and
attitudes that promote recognition and appropriate help seeking.

Activities designed to improve mental health literacy are a significant component of
mental health promotion. Strategies for improving mental health literacy generally
comprise education and communication approaches. These activities may be
classified in a number of different ways, and can be considered in terms of:
scope universal preventive measures (i.e. targeting the whole population or
population groups), or selective preventive measures (i.e. aimed at particular
subgroups of the population);
mode of delivery e.g. mass media, brochures, oral presentations by experts
and/or community leaders etc., and whether these modes are used in isolation
or in combination;
scale small (e.g. local) or large (e.g. national); and
setting e.g. whole communities, hospitals, schools etc.

Recent studies of mental health literacy in Australia have shown that the public are
not very well informed about mental illness. A survey conducted in 2001 showed that
90% of respondents believed mental health was a significant issue in Australia, but
overall did not have a clear understanding of mental illness (Wirthlin Worldwide
Australasia Pty Ltd, 2001). In an earlier study, J orm et al (1997) found that members
of the public tended to view pharmacological treatments for depression and
9
schizophrenia as harmful, and to have a relatively negative view of mental health
specialists compared with other health professionals. J orm et al stated that the level of
mental health literacy in the population should be improved in order for individuals to
recognise mental illness and manage their own mental health more effectively.

Improving mental health literacy in the general population is also important in terms
of overcoming stigma associated with mental illness. Stigma can lead to prejudice,
discrimination and negative outcomes for people with mental illness (Corrigan and
Penn 1999; Commonwealth Department of Health and Aged Care, 2000b). In a
review of the literature on the stigma of mental illness, Hayward and Bright (1997)
defined stigma as the negative effects of a label placed on any group . . . in this case,
those who have been diagnosed as mentally ill. Corrigan and Penn (1999) stated
that the impact of stigma on a persons life might be as harmful as the effects of the
mental illness.

The attitudes of the public towards mental health issues are recognised as an
important factor in the perpetuation of the stigma experienced by people with mental
illness (Commonwealth Department of Health and Aged Care, 2000a; Kommana et al,
1997). Research has indicated that those with a better understanding of mental illness
are less likely to hold stigmatising attitudes (Link and Cullen 1986; Brockington et al
1993; Wolff et al 1996; 1996b; Corrigan and Penn 1999). Kommana et al (1997)
discussed the role of social psychology theory and attitude change in overcoming
stigma, stating that changing public attitudes was a crucial step in eliminating stigma.
They argued that stereotypes and misconceptions can be dispelled by promoting direct
contact between the general public and people with mental illnesses, however, they
also stated that overcoming stigma may be achieved more efficiently by disseminating
realistic information through public education campaigns.
Purpose of the review
The aim of this literature review is to evaluate and interpret current research relating
to improving mental health literacy, in order to identify the most effective
communication strategies and tools to improve mental health literacy among target
audiences in the Australian population. The literature review involves a systematic
examination of the available research. It is systematic in that it: a) makes a concerted
effort to identify all relevant research; b) makes judgements about the overall quality
of the literature; c) systematically draws together the findings of the studies that are
judged to be of acceptable quality for inclusion in the review; and d) makes
judgements about the efficacy of particular interventions.

In addition, this report considers research relating to public health communication
strategies, in order to provide an overview of effective health communication
approaches that may be applicable to programs designed to improve mental health
literacy. While an in-depth review of all the literature in this area is beyond the scope
of the current review, an analysis of health communication strategies is outlined in
Section 4 of this report, and a summary of key systematic reviews of health
communication campaigns is provided in Appendix 1.
Research question
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Supplementary questions:
a) To what extent have such strategies improved levels of knowledge and awareness,
achieved attitudinal change and/or behavioural change and/or achieved positive
changes to broader community attitudes which may have had a flow-on effect to
mental health consumers?
b) What are the determinants of successful public health information strategies, for
example, strategy development, selling the message, communication tools (eg
print, radio, television and/or film), post-strategy follow-up and cost
effectiveness?
c) Which determinants of successful strategies and campaigns apply to all
populations and which to particular target audiences?
d) Which successful public health information strategy models are transferable in
terms of content and/or process across topic areas and/or demographic groups in
Australia?
e) In which areas may further research be commissioned on public health
information approaches to mental health literacy?
Method
Literature retrieval
Relevant literature relating to mental health literacy programs was identified through
a number of database searches. The literature review aimed to identify recent
research; therefore appropriate databases were searched for English language articles
dated from 1980 to May 2002. The databases searched included: Medline,
PsychINFO, Current Contents, Communication Abstracts, Cochrane Database of
Systematic Reviews, EMB Reviews, York Database of Abstracts of Reviews of
Effectiveness, and ProQuest. The following truncated search terms were employed:

mental*, psychiatr*

health, illness*, disorder*, wellbeing

promot*, prevent*, literacy, educat*, communication campaign, information

The reference lists of relevant articles retrieved through database searches were also
scanned in order to identify other important studies for inclusion in the literature
review.

In addition to database searches, efforts were made to uncover unpublished work of
relevance to the literature review. In particular, contact was made with a number of
researchers in the field both in Australia and overseas. This contact resulted in the
inclusion of several unpublished studies in the literature review.
Inclusion criteria
Studies included in the literature review were those which evaluated programs
designed to improve general mental health literacy in the population. A large number
of studies were identified through the literature retrieval process described above,
however not all studies were of relevance to the literature review. Many studies were
excluded from the review as they did not focus on mental health literacy programs,
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and the content was therefore not applicable. It should be noted, however, that the
term mental health literacy is not widely used in the literature. Programs designed to
improve mental health literacy are more commonly described as mental health
education or information programs.

The more general terms mental health promotion and mental illness prevention may
also refer to programs that are designed specifically to improve mental health literacy.
However, not all mental health promotion and prevention programs fall into this
category. For example, a number of mental health promotion programs focus on skills
development or early intervention methods, which are outside the scope of this
review. Only those programs that addressed the issue of mental health literacy were
selected for inclusion.

It should be noted that previous literature reviews have considered the issue of mental
health literacy in the context of the broader concepts of mental health promotion and
mental illness prevention. An overview of this literature is given in Appendix 1 of this
report. In addition, key systematic reviews of other forms of health communication
campaigns are outlined in Appendix 1.
Exclusion criteria
Sections of the literature that did not specifically involve an evaluation of a program
to improve mental health literacy were excluded from the review. Programs that were
specifically designed to provide training for mental health professionals were also
excluded, as these programs were not targeted to the general Australian population. A
number of studies were identified which described the development of particular
programs, but did not include an evaluation, and these studies were also excluded
from the review. In addition, certain studies that provided an evaluation were not of
sufficient strength or methodological rigour to include in the review.
Classification of literature
The relevant literature involving programs to improve mental health literacy was
identified and classified according to the following general categories:


Within these categories, studies differed in their mode of delivery, scale and setting.
All studies involved an evaluation of an intervention, however there was variability in
terms of their study design. Only two of the studies identified for inclusion in the
review used an experimental, randomised controlled trial design. A large proportion
of the studies were quasi-experimental in design, that is, they used intervention and
control groups but did not use randomisation of participants. Most studies also
involved a pre-test/post-test design, with surveys of study participants prior to and
following the program. (See Section 5 for discussion of methodological issues)
Data extraction
Information relevant to the effectiveness of individual programs was extracted from
each of the studies. This included the author and year of the study, the mode of
delivery, setting and content of the program, the study design, the overall method, the
key findings, and conclusions of the study. The methodological issues and limitations
12
of each study were also examined, in order to determine the validity and importance
of any findings. A detailed review of each of the studies is provided in Sections 2 and
3 of this report, along with tables of key findings.
Data synthesis
The data extracted from the studies were drawn together in order to provide a
descriptive review of the effectiveness of different programs to improve mental health
literacy. The data did not lend itself to a formal meta-analysis, as the studies included
in the review were conducted in different settings and used a variety of research
designs. In addition, the quality of studies varied widely, and therefore the findings of
better quality studies were separated from those of poorer quality evaluations. As a
result, the synthesis of data involved identification of trends in order to determine
which interventions were most effective in achieving positive outcomes.

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2. Review of individual studies - Whole of
community programs

A variety of programs have addressed the issue of improving mental health literacy at
a whole of community level. A total of eight programs were identified which had
been formally evaluated and fulfilled the inclusion criteria for the review. Most of
these programs involved mass media campaigns, however a small number of studies
used other modes of delivery, such as education courses. Only one of the studies was
conducted in Australia, with the remaining studies conducted in the United Kingdom,
the United States, Canada and Norway. While there was a large variability in the
types of interventions studied, the overall findings were that positive changes in levels
of mental health literacy and awareness were obtained. The key findings from each of
the studies are presented in Table 1.
Mass media campaigns
A number of studies have looked at the impact of mass media programs to improve
mental health literacy. Mass media programs are a common method of conveying
health information to the general public, as it is perceived that a wide audience may
be reached. Such approaches may, for example, involve campaigns in broadcast and
print media, or may provide health information through entertainment or news
programs on broadcast media. Studies of mental health literacy campaigns in the mass
media indicate that there is potential for such programs to have an impact on
community attitudes, knowledge and behavioural intentions.

A series of studies from the UK investigated the impact of a five-year campaign
designed to raise awareness of mental illness (Priest et al 1996; Paykel et al. 1997;
1998). The studies looked at the Defeat Depression campaign, organised by the Royal
College of Psychiatrists and the Royal College of General Practitioners. The aim of
the campaign was to reduce the stigma associated with depression, educate the
community about the condition, and encourage early help-seeking behaviour. The
campaign was run between 1991 and 1996 and involved wide-ranging media
activities, including newspaper and magazine articles, and radio and television
programs.

Media activities for the campaign began with a press conference in 1992, which
resulted in widespread newspaper, radio and television reports about depression.
Other media events included reports of personal experience of depression by several
high profile individuals. Publications including leaflets and books were produced and
disseminated widely. Audiocassettes and videotapes promoting coping techniques for
people with depression were also produced. A special Defeat Depression Action
Week was held in 1994, involving media briefings and community activities, and
further Action Days were held in 1995 and 1996. In addition, a number of fact sheets
were prepared in different languages to reach people from non-English speaking
backgrounds (see Section 3 for a review of this aspect of the campaign).

In order to measure the impact of the campaign, the study involved three surveys
conducted in 1991, 1995 and 1997. The samples were selected using a quota sampling
method, which involved the selection of weighted samples on the basis of their known

14
representation in the population. This resulted in sample sizes of around 2000 in each
of the survey years. The surveys involved face-to-face interviews, with the same 25
questions asked in each of the three surveys. The questions related to the respondents
perceptions of depression, opinions about the treatment of depression, and views
about general practitioners.

The survey results showed that the attitudes of respondents to depression were very
positive on all three occasions, with little variation over time. Throughout the study,
approximately 10% of participants agreed with the negative statement that depressed
people are often mad or unstable, while around 97% felt that anybody can suffer
from depression. There was a slight increase in the proportion of respondents who
reported experiencing depression themselves in 1997 (25%) compared with the first
survey in 1991 (22%). Respondents tended to view the causes of depression as largely
psychosocial rather than physical, with almost all causes of depression endorsed more
strongly in the later survey years when compared with the first survey. In terms of
treatment, counselling was much more frequently endorsed than antidepressant
medication, however the proportion of respondents agreeing that antidepressants were
effective increased from 46% in 1991 to 60% in 1997. When asked about general
practitioners, the majority of respondents agreed that they would approach their GP or
other health professional if they suffered from depression. The proportion of
respondents who stated they would seek help from their GP rose from 60% in 1991 to
68% in 1997.

The authors concluded that there were significant positive changes in attitudes over
the course of the campaign. General attitudes to depression were very positive from
the beginning of the campaign, and did not alter significantly. Although
antidepressants were not viewed as positively as counselling in terms of treatment
options, attitudes to antidepressant medication improved during the campaign. It is
important to note that the authors acknowledged that they could not be certain that the
campaign had caused the attitudinal changes described in the study. While they stated
that there was a significant increase in media coverage of mental health issues during
the campaign, it was noted that very few of the respondents reported that they had
heard directly of the campaign (5% in 1995 and 2% in 1997).

A comparable campaign undertaken recently in Australia as part of the Community
Awareness Program (CAP) was reviewed in 1999 (Evans Research 1999). The
program aimed to increase awareness of mental health issues and reduce stigma and
discrimination associated with mental illness. The program was launched in 1995 and,
along with a number of media activities including television commercials, involved
the production and dissemination of mental health information brochures. The series
of brochures covered the following topics: mental illness, stigma, the National Mental
Health Strategy, depression, anxiety, eating disorders, schizophrenia, and bipolar
disorder. The review undertaken in 1999 looked specifically at the mental health
information brochures, and aimed to make recommendations regarding the further
development of campaign materials.

The review involved consultation with key stakeholders and experts to evaluate the
effectiveness of the mental health information brochures. This consultation comprised
written evaluation questionnaires, written and telephone surveys, and meetings with
stakeholder groups. The questionnaires were given to 660 general practitioners in

15
metropolitan Melbourne, as well as 960 medical practitioners and psychologists
nationwide, and representatives of mental health organisations. Telephone interviews
were conducted with representatives from mental health organisations, consumer
groups, and other key stakeholders.

A total of 163 general practitioners completed the questionnaires, to give a response
rate of 25%. Approximately half of the respondents (52%) reported seeing each of the
brochures. For those who reported having seen the material, all brochures were rated
as highly useful on a 10-point utility scale. In addition, the brochure providing
information about schizophrenia was selected by the greatest proportion of
respondents as the most useful. The best features of the brochures were found to be
their readability and educational role, and the most commonly suggested
improvements were increased availability and provision of service availability on the
brochures. Amongst medical practitioners and psychologists, a response rate of 26%
to the questionnaire was obtained. A slightly greater proportion (57%) of respondents
reported familiarity with the brochures, compared with the sample of general
practitioners. All brochures were rated as highly useful, although the utility scores
were lower overall than those reported by the general practitioner group. Once again,
the brochure on schizophrenia was most commonly cited as the most useful, and the
best features of the brochures overall were their educational role and readability.

A total of 18 representatives from mental health organisation responded to the survey,
however the response rate was not provided. All reported seeing the information
brochures, and, as with the other two sample groups, all brochures were rated highly
on the utility scale. Again the most useful brochure was that providing information
about schizophrenia. The best features of the brochures were reported to be the
readability and presentation, and suggested improvements were expanded availability,
inclusion of service availability, and production of brochures in other languages.
Participants from stakeholder groups who were contacted by telephone indicated a
high level of familiarity with the brochures, with 76% reporting that they had seen the
brochures. Respondents once again reported that readability was the best feature of
the brochures. In addition, around 40% of respondents endorsed the role of the CAP
information brochures, and 27% felt there was a need to improve distribution.

Following consultation with key stakeholder groups, a number of recommendations
were made about changes to the titles of various brochures, as well as content
revisions, design improvements, and the production of a main brochure in a range of
different languages. It was felt to be important to include contact details for relevant
mental health services, and to outline re-ordering information. Recommendations for
new materials included an expanded set of titles, and the use of an integrated
brochure, CD-ROM and web site. Suggestions were also made regarding the use of
specific media for particular target groups. For example, recommended strategies for
targeting young people were: television commercials and popular television programs,
advertisements in youth magazines, information in school libraries and youth-oriented
corporate sponsorship.

The review concluded that the CAP mental health information brochures had been
well received and had provided a useful education resource. It was recommended that
the focus of the information brochures on mental health education and promotion
should remain. However, they also stated that the distribution of brochures had been

16
inadequate, as only around half of the medical practitioners and psychologists
surveyed reported seeing the brochures. Recommendations were made for improving
the distribution approach, through collaboration with State and Territory health
departments, professional associations, peak mental health organisations, hospitals
and libraries. The authors also stated that there was a need for ongoing evaluation of
the dissemination of the materials, and surveys of community knowledge and attitudes
about mental health issues in Australia. It is important to note that the evaluation of
the brochures in 1999 did not include surveys of community attitudes, or attempt to
measure the impact of the mental health information brochures on community
attitudes.

Unlike the broad-ranging media campaigns already described, an earlier study from
the UK by Barker et al (1993) investigated the impact of television series designed to
provide information about mental illness to the general public. The series, entitled You
in Mind, consisted of seven ten-minute programs presenting information about mental
health problems and providing examples of coping methods. The aim of the series
was to provide insight, problem clarification and problem solving techniques in terms
of the viewers own problems, and their perceptions of the problems of others. The
programs were designed to be positive in tone, and generally depicted ordinary people
describing methods of coping with common emotional and psychological problems.
The program titles were: The Tranquiliser Trap, Being Assertive, Overcoming
Insomnia, Overcoming Fear, Overcoming Depression, Expressing Feelings, and
Change. The series was televised in the UK on Sunday evenings from February to
April in 1987 and received an audience of approximately 13% of the adult population.
A written booklet was also available, and provided information about the topics
covered in the series, as well as details of national and local mental health services.

The aim of the study was to measure the impact of the series on community attitudes
and behaviour. Baseline data were collected from a representative national sample of
1040 adults prior to the beginning of the series. Participants were then sent a follow-
up questionnaire one year later, after the series was completed, which received a 52%
response rate. Of these, only 62 participants had viewed the series. Respondents were
asked questions about coping and help-seeking measures, as well as general responses
to the series.

The results of the study were that those who had viewed the series found that it was
useful in terms of insight, problem clarification and problem solving. However, it was
found that the series had a greater impact in the areas of awareness and clarification
than in actually finding out how to respond to problems. Over 75% of viewers felt that
the series portrayed people similar to people they knew, but half of the viewers
thought that the series was not actually relevant to their own concerns. In terms of
behaviour change, 45% of viewers stated that they had either tried or intended to try
new methods of coping with their own problems. However, the authors also noted that
the figures relating to reported behaviour change should be treated with some caution,
as a validity check on one of the measures of behaviour change had revealed a
significant amount of over-reporting.

The authors concluded that there was some evidence that the series had a positive
impact on viewers. However, it was apparent that the series had a greater impact on
viewers perceptions of other peoples problems than of their own. It was argued that

17
this was most likely because there was a higher probability of respondents knowing of
other people with a mental illness than of having a mental illness themselves, and also
that a proportion of the participants may have chosen to deny their own mental health
problems. Although the authors acknowledged a large degree of over-reporting of
behaviour change, a significant number of viewers stated that they had changed or
intended to change their behaviour as a result of the series. The authors argued that,
while any significant impacts of the series were limited to a minority of the
respondents, this proportion, when translated into the actual total national audience,
would be a large absolute number.

A mass media campaign conducted in Norway in 1992 used a slightly different
approach, and indicated particularly positive results (Fonnebo and Sogaard 1995;
Sogaard and Fonnebo 1995). The objectives of the Norwegian Mental Health
Campaign were to raise money for psychiatric research, and to educate the
community about the treatment and prevention of mental health disorders. The
campaign centred around a fund-raising television program, which was broadcast in
1992 on a nationwide television station. The six-hour television program included
information about mental health issues, as well as entertainment and fund-raising
activities. Prior to the broadcast of the program, there was extensive coverage of the
campaign through newspaper and television advertisements, and through a series of
educational television and radio programs about mental illness. In addition, a
campaign newspaper was sent to every household, and information about the
campaign was distributed to a number of organizations including community health
centres, schools, libraries and psychiatric institutions. The campaign was formally
endorsed by the government, and received support from the King and Queen of
Norway, as well as a number of church organisations. Community activities including
an essay competition and a celebrity gala event were also organised to coincide with
the campaign.

The evaluation of the program involved telephone interviews with a random sample
of the population. Prior to the campaign, 1191 individuals were interviewed regarding
knowledge of and attitudes to mental health disorders. One month after the campaign,
644 (54%) of the original participants were interviewed again. Of these, 574
respondents had heard of the campaign, which represented 94% of the follow-up
sample. Approximately two-thirds of all respondents had watched pre-campaign
television programs, and 62% indicated that they had viewed the television program
on the day of the campaign. A total of 68% of respondents had read information
connected with the campaign about mental health issues, and almost half reported
discussing the theme of the campaign with others. The follow-up survey was also
administered to a separate sample of 1177 individuals, to control for any effects of
repeated interviewing in the original sample.

The 574 respondents in the follow-up sample who reported that they had heard of the
campaign were included in the evaluation of the impact of the program in terms of
changes in knowledge and attitudes. It was found that there were significant increases
in knowledge about suicide frequency following the campaign. For example, the
proportion of male respondents who correctly indicated that suicide deaths are more
common than traffic accident deaths roles from 28% prior to the campaign to 43% at
follow-up. The corresponding proportions for female respondents rose from 21% at
baseline to 46% after the campaign. Knowledge about aspects of mental illness other

18
than suicide frequency did not change significantly following the campaign. It was
found that, throughout the campaign, there were significant increases in the
proportion of respondents who were willing to be open about family members who
were hospitalised for a psychiatric disorder, as well as improved attitudes to help-
seeking.

The authors concluded that the campaign had resulted in significant changes in
knowledge and attitudes in study participants. They stated that the campaign had
reached all but 6% of the Norwegian population over 14 years of age, which indicates
that the level of awareness of the campaign was much greater than that of other
nation-wide mass media approaches, such as the Defeat Depression campaign in the
UK, which had an awareness level of only 5% of respondents (Paykel et al. 1997;
1998). The authors stated that the success of the campaign in terms of population
penetration was due to its thorough planning, and the use of appropriate mass media
and social marketing theories. They argued that the mass media are an effective
vehicle for conveying information to the population as a whole, and that collaboration
with the national media, public figures, and the Norwegian Council of Mental Health
had enabled the campaign to attract widespread attention. Importantly, the authors
noted that long-term follow-up was important to determine whether changes had been
maintained. They stated that a follow-up survey would be conducted in 1995,
however the results of this new survey do not appear to have been published.

In contrast to the large-scale mass media campaigns already mentioned, two studies
looked at the impact of educational films on attitudes to mental illness. Medvene and
Bridge (1990) conducted a study in the US that looked at the impact of a television
documentary entitled Back Wards to Back Streets, which was designed to improve
information levels and attitudes towards community-based treatment facilities for
mental illness. The structure of the film followed a contact hypothesis approach,
which promotes the concept that direct contact and interaction between different
groups can change stereotypes and lead to more positive attitudes (Amir 1976). The
aim of the documentary was to bring the audience into contact with individuals who
had been in psychiatric hospitals, using the medium of television. The content of the
film comprised personal interviews with 14 individuals, who each described their
experiences of community-based treatment.

Participants in the evaluation consisted of selected mental health professionals,
policy-makers, and members of the public in New York and Albany. The two groups
of participants (405 in New York and 136 in Albany) were shown the documentary
and then asked to complete questionnaires about community-based treatment facilities
and their beliefs about mental illness. Half of the participants were also given the
same questionnaire prior to viewing the documentary. In addition, several discussion
groups were organised to obtain qualitative data from some of the participants who
had viewed the documentary.

Participants in the New York City group showed significantly improved information
levels and attitudes towards community-based treatment facilities after viewing the
documentary. Beliefs about mental illness and mental health care amongst members
of this group also changed, and more than 90% of this audience indicated that the film
was good and informative. The impact was found to be the same for mental health
professionals, policy-makers and public members of the audience. By comparison, the

19
Albany group did not show significant changes in information levels or attitudes after
viewing the documentary, but over 90% of the audience found the film to be good.
The authors pointed out that the Albany group were better informed about issues
related to community-treatment facilities than the New York group prior to seeing the
film, and this may explain why attitudes and information levels did not change
significantly in the Albany group. The authors concluded that television programs can
alter information levels and attitudes to mental health issues among specific groups,
and argued that the success of the documentary was a result of its personalised format,
with the vast majority of the audience members indicating that the program was both
enjoyable and informative.

A similar study by Tolomiczenko et al (2001) investigated the impact of a video film
about homelessness and mental illness, but found less encouraging results. The aim of
the study was to determine whether the video would be an effective tool for educating
the public and improving attitudes to homeless people with mental illness. The video,
entitled A Fine Line, depicted caseworkers, clients and psychiatrists involved in the
Hostel Outreach Program in Toronto, Canada. In the film, the clients spoke about the
course of their illness, and its relationship to their homelessness. The clients also
conducted interviews with caseworkers and mental health professionals, who
described the Hostel Outreach Program and its impact on homeless people with
mental illness.

The evaluation of the video was conducted as part of a regular public education
program run by the Centre for Addiction and Mental Health in Toronto. The
education program generally comprised a tour of the centre, a video, discussions with
people who have mental illness, group exercises and overviews of psychiatric
terminology. For the purposes of the study, the regular education program acted as the
control condition, and two variations of the program provided two different
interventions. The first intervention, called the video group, included the video A
Fine Line in place of the video routinely used in the program. The second
intervention, entitled the video plus discussion group, utilised the video A Fine Line
along with a follow-up discussion with one of the clients featured in the video
presentation. The authors hypothesised that the intervention video would have a
positive impact on attitudes to and understanding of homelessness, and that this effect
would be enhanced by the follow-up discussion in the video plus discussion
intervention.

Participants in the study comprised 575 high school students from 14 different schools
who attended the public education program and completed assessment questionnaires.
The questionnaires consisted of items relating to: exposure to homeless people,
emotional responsiveness and empathy, attitude to mental illness, beliefs about
dangerousness, aversion, restrictive beliefs, structural determinants of homelessness,
disability, and blame. Of the 575 participants, 214 were in the video group, 186
comprised the video plus discussion group, and the remaining 175 formed the control
group, who undertook the regular education program.

Participants completed questionnaires at post-intervention only. The results indicated
that certain factors were significantly associated with more positive attitudes to
homelessness and mental illness. Females had more positive attitudes than males, and
those who had greater level of prior exposure to homeless people also showed more

20
positive attitudes to homelessness than those with lower exposure. With respect to the
intervention groups, it was found that the video group had more negative attitudes to
mental illness and homeless people than participants in other groups. In particular,
participants in the video group held more negative beliefs about mental illness, and
indicated stronger feelings of danger associated with homeless people. Participants
who saw the video, with or without the follow-up discussion, were also more likely to
endorse restrictions of homeless people, and to view disability as a cause of
homelessness, compared with the control group. In contrast, the video plus discussion
group showed more positive attitudes than the control group in terms of attitudes to
mental illness and beliefs about dangerousness.

The authors concluded that the hypothesis had not been supported by the results of the
study, as the findings indicated that the video had in fact resulted in more negative
attitudes to mental illness and homelessness. The positive findings were that the
combination of the video plus discussion with a homeless person resulted in some
improvement in attitudes. Other factors that were associated with positive attitudes
were being female and having higher level of previous exposure to people who are
homeless. The authors stated that direct contact with people with a mental illness was
important in reducing stigmatising attitudes. They also recommended that educational
media messages about mental illness and homelessness should be carefully targeted to
particular audiences to ensure that negative attitudes were not reinforced. A lack of
appropriate planning may explain why the study did not achieve positive attitude
changes similar to those found by Medvene and Bridge (1990).
Other modes of delivery
While a diverse range of studies has focused on mass media strategies, there has been
relatively little research investigating the impact of other approaches to mental health
education on a whole of community level. A series of studies from the U.K. by Wolff
et al (1996a; 1996b; 1996c) investigated the impact of a localised public education
campaign on community attitudes to people with mental illness. The studies involved
a survey of attitudes towards in two areas of South London (Streatham Hill and Herne
Hill) prior to the opening of supported accommodation houses for people with mental
illness. When the supported accommodation facilities began operating in 1993, an
education campaign was conducted in only one of the areas, and the attitude survey
then repeated in both areas.

The education campaign comprised three elements: a social component, including
social events and social interaction with staff; a didactic component, consisting of an
information video and written material; and a mixed component, consisting of a
formal reception and informal discussion meetings. The campaign was developed in
consultation with staff from the supported accommodation houses, and the residents
gave their consent for the campaign. The authors noted, however, that a number of
objections to the campaign were raised by the community mental health staff, who felt
that it would not be of benefit to the residents of the facility.

The surveys conducted prior to and following the education campaign involved face-
to-face interviews and included questions dealing with knowledge of mental illness
and mental health care, and attitudes to people with mental illness. In order to provide
a measure of attitudes, participants were given the Community Attitudes to the
Mentally Ill (CAMI) questionnaire. The CAMI questionnaire is a self-report

21
instrument containing 40 statements, which is designed to measure community
attitudes to people with mental illness. Respondents indicate the extent to which they
agree with each statement, from strongly agree to strongly disagree. For the purposes
of this study, participants were also given a 10-item questionnaire focusing on fear of
and behavioural intentions toward people with mental illness. During the follow-up
survey, participants were also asked about their levels of contact with staff and
patients from the supported houses.

The first survey indicated that the majority of the 215 participants held positive
attitudes to people with mental illness. Three attitudinal factors measured by the
CAMI questionnaire emerged as being of particular importance: Fear and Exclusion,
Social Control, and Goodwill. Although there were found to be no overall differences
in attitudes between the two survey areas at the beginning of the study, a significant
minority in both areas were found to hold views that were fearful and socially
controlling. The vast majority of respondents (91%) reported a desire for further
information, however the authors noted that only one-third of participants in the
experimental area actually accepted the offer of educational material during the
campaign.

Following the public education campaign, 109 of the original 215 participants were
interviewed again. The authors noted that those who had expressed more negative
attitudes in the initial interview were more likely to refuse the second interview. The
results of the second interview were that there was a small increase in knowledge in
the intervention area, which had received the educational campaign, compared with
the control area. In terms of changes in attitudes measured by the CAMI
questionnaire, it was found that there was a decrease in Fear and Exclusion in the
experimental area compared with the control area, but no change in Social Control or
Goodwill. There was also an increase in reported positive behavioural intentions in
the intervention area, with no corresponding change in the control area. Participants
from the experimental area were significantly more likely to have made contact with
staff and patients than those in the control area, and those in the experimental area
who had made contact with patients were more likely to show a decrease in Fear and
Exclusion over time.

Overall, the public education campaign was associated with an improvement in
overall attitudes and behaviour towards people with a mental illness, but had only a
modest effect on knowledge. The authors stated that higher levels of contact with
patients, rather than the education campaign per se, resulted in less fearful attitudes in
the experimental area. It was recommended that future education campaigns should be
targeted more specifically towards those with the most negative attitudes to people
with a mental illness.

The impact of another short-term education program was evaluated by Holmes et al
(1999). The aim of this particular study was to measure the effects of an educational
program on attitudes to mental illness, and to determine whether the impact of the
program was modified by pre-existing knowledge and experience. The program
involved a semester-long course about severe mental illness that was delivered to a
total of 35 adult participants who were enrolled at a community college in
metropolitan Chicago. The course, entitled Severe Mental Illness and Psychiatric
Rehabilitation, was designed to provide accurate information and dispel

22
misconceptions about schizophrenia. It covered information about the causes,
treatment and prognosis of schizophrenia, rehabilitation for people with psychiatric
disability, and a review of the evidence relating to dangerousness. In addition, two
presentations were given by a mental health consumer and a family member, with the
intention of reducing negative attitudes to mental illness through direct contact.

Participants completed the course in three groups of 10 to 14 students, and the study
was conducted over three separate semesters. A control group of 48 participants was
recruited from adult students enrolled in a general psychology course at the same
college. Participants from both the intervention and control groups completed
questionnaires prior to and following the education course. Two questionnaires were
designed specifically for the study in order to measure knowledge of mental illness
and contact with people with severe mental illness. In addition, attitudes were
measured using the Opinions about Mental Illness (OMI) questionnaire. The OMI
questionnaire comprises 70 statements about mental illness to which respondents
indicate their level agreement on a six-point scale. Three subscales measured by the
OMI questionnaire were selected for this study: authoritarianism, benevolence, and
social restrictiveness.

It was found that participants in the intervention group showed significant
improvement in knowledge about mental illness following the education course,
however no corresponding change was found in the control group. Participants in the
intervention group also showed significantly improved benevolence and social
restrictiveness attitudes on the OMI questionnaire, while control group participants
demonstrated improvement on benevolence scores only. No significant change was
found in authoritarian attitudes for either group.

When the results were analysed to determine the impact of prior knowledge and
contact with mental illness, it was found that these variables were significantly
associated with a number of changes in attitudes measured by the OMI questionnaire.
Specifically, participants with a higher level of knowledge or contact with severe
mental illness prior to the program demonstrated significantly greater improvement in
benevolence attitudes following the education program. These improvements were
greater for participants in the intervention group, compared with changes in the
control group. In contrast, prior level of contact was associated negatively with
changes in social restrictiveness score. Those who reported least contact with severe
mental illness prior to the program demonstrated greater improvements in social
restrictiveness attitudes following the education course.

The authors concluded that the education course had improved attitudes to mental
illness. In particular, it was found that benevolence and social restrictiveness attitudes
improved throughout the education program. A change in benevolence attitudes was
also found in the control group during the study, however this was smaller in
magnitude than that of the intervention group. The authors stated that pre-education
knowledge and contact with mental illness mediated the effects of the educational
program. Prior knowledge and contact were found to augment improvements in
benevolence attitudes. This supports the finding of Wolff et al (1996a; 1996b; 1996c)
that improved attitudes were associated with social contact with people with mental
illness, rather than education alone. In contrast, Holmes et al also found that prior
knowledge and contact were negatively associated with social restrictiveness scores.

23
The authors noted that they were unable to determine which particular components of
the education course were associated with attitude change, and it is not known
whether changes were maintained in the long term.
Methodological issues
A range of important methodological issues and limitations were raised in the
literature outlined above. For example, evaluations of the Defeat Depression
campaign were limited in that they did not involve the use of a concurrent control
group for comparison with the intervention group (Priest et al 1996; Paykel et al1997;
1998). The authors stated that, because the campaign was run at a national level, it
was not possible to include a control group. This was also the case with the evaluation
of the Norwegian Mental Health Campaign (Fonnebo and Sogaard 1995; Sogaard and
Fonnebo 1995). These studies both involved a pre-test/post-test design, which means
that measurements of attitudes were taken at the beginning of the study, enabling the
intervention groups to act as their own controls. It is important to note, however, that
the lack of concurrent control groups is a weakness in long-term studies. As a result of
this limitation, it is unclear whether the attitudinal changes described in each study
were in fact associated with campaign activities. In particular, Paykel et al noted that
very few of the participants in their study reported that they had actually heard of the
campaign, which may indicate that other factors were involved in the attitudinal
changes identified. In addition, many of the improvements in knowledge and attitudes
found in the studies were quite small in magnitude.

The review of the Community Awareness Program (Evans Research 1999) in
Australia differed from most other studies in this section in that it involved a post-test
only design, and as the intervention occurred at a national level the study did not
involve a control group. Tolomiczenko et al (2001) also conducted a post-test only
study, and therefore were unable to show whether attitudes had in fact changed over
the course of the interventions. While the study did involve concurrent controls, the
authors did not compare the characteristics of the different intervention and control
groups. It is therefore unclear whether the groups were similar, and whether attitudes
varied between the groups prior to the intervention. Although the program was
intended to educate the general public, the study sample was limited to high school
students, which may limit the generalisability of the findings to the general
population.

Evaluations of the Norwegian Mental Health Campaign (Fonnebo and Sogaard 1995;
Sogaard and Fonnebo 1995) involved a control group for the post-test interview only,
to control for the possible confounding factor of being interviewed prior to the
commencement of the campaign. Of the original sample in this study, only 54% were
interviewed at follow-up, which indicates a high level of attrition. The authors noted
that the characteristics of the follow-up sample were slightly different from that of the
total population, with an over-representation of women aged 25 to 39 years. It was
found, however, that there were no significant differences between the follow-up
sample and the control sample in terms of levels of awareness and interest in the
campaign, indicating that there were no serious biases in the follow-up sample to
account for the observed changes in attitudes following the campaign.

Methodological issues relating to sampling were also described by Wolff et al (1996a;
1996b; 1996c), who stated that, in their study of community attitudes, the

24
demographic characteristics of the participants in the control group were slightly
different from those in the intervention group. While there were no overall differences
in attitudes between the two groups prior to the campaign, the authors acknowledged
that the study sample was not representative of the overall population. In particular,
there was an over-representation of people from higher social class and from
particular ethnic groups. The authors stated that conclusions about the applicability of
the findings to the general population could be tentative only. It is also important to
note that, in the follow-up survey of attitudes, participants who had expressed more
negative attitudes at baseline were also more likely to refuse the second interview.
This may have resulted in a biased follow-up sample, and could account for some of
the improvement in attitudes found following the educational intervention.

Holmes et al (1999) found in their study that the demographic characteristics of
participants in the intervention group were similar to the population as a whole,
however there were differences between the intervention and control groups.
Participants were not randomly assigned to groups, and the authors acknowledged that
the differences noted may have been a confounding factor in the results of the study.
The authors stated that the general psychology course undertaken by the control group
did not specifically provide information about severe mental illness and issues of
stigma, and therefore had not been expected to result in significant changes in
attitudes. Despite this, it was found that benevolence attitudes significantly improved
in the control group, and it was argued that differences in mean age between the two
groups may have been associated with this unexpected finding.

Specific issues were raised in the study by Barker et al (1993), which investigated the
impact of the television series You in Mind. The authors acknowledged that the study
design proved to be insufficiently sensitive to measure much of the impact of interest.
Although the study used an initial sample size of 1040, there was a low response rate
for the follow-up questionnaire, with only 52% of initial participants providing
follow-up information. This was similar to the response rate obtained in the
evaluation of the Norwegian Mental Health Campaign (Fonnebo and Sogaard 1995;
Sogaard and Fonnebo 1995). In contrast to the Norwegian campaign, however, only a
small minority of respondents in the UK study had actually viewed the television
series, making it difficult to compare those who had viewed the series with the much
larger group who had not.

The study by Medvene and Bridge (1990), while showing quite positive results in one
of the study groups, also had a number of important limitations. The participants were
not randomly selected, and the majority were mental health professionals who may be
expected to be more receptive to information about mental health issues than the
general public. This is a significant factor when considering the generalisability of the
findings to the population as a whole. Similarly, the review of the Community
Awareness Program (Evans Research 1999) in Australia did not involve a random
sample of the population, as participants in the study were chosen from particular
professional and consumer groups. In addition, there was a very low response rate to
the surveys of general practitioners (25%) and other medical and mental health
professionals (26%), and it is possible that those responding to the survey were not
representative of the overall target group. As a result of the studys methodological
issues, it is difficult to draw valid conclusions about the usefulness of the information
brochures for improving community awareness. Although the study attempted to

25
quantify survey findings in terms of levels of awareness and usefulness of the
brochures, the key findings of the study were more qualitative, and related to
recommendations for improvements in distribution and content of future educational
materials.

Another important methodological issue in many of the studies was that measures
tended to rely on self-reporting, particularly those relating to aspects of behaviour
change. Paykel et al (1997; 1998) acknowledged in their study that it was not possible
to measure the validity of reported intentions to change behaviour, and this may have
caused a large degree of over-reporting. Importantly, Barker et al (1993) noted in their
study of the television series You in Mind that validity checks had indicated
considerable over-reporting in terms of behaviour change amongst study participants.
Summary
Despite important methodological limitations, the literature indicates that mass media
campaigns can have a positive impact on levels of mental health literacy in the
population. These findings are consistent with conclusions drawn from more general
communication research literature (see Section 4). Evaluations of programs conducted
at national and statewide levels generally indicated that attitudes and knowledge
improved; however the extent of changes was acknowledged to be limited. There
were some indications of positive changes in behavioural intentions and reported
behaviour, however the reliability of self-reported behaviour changes was not able to
be determined.

Mass media programs included in this review varied in terms of audience penetration.
A Norwegian program reportedly reached 94% of the population, compared with
levels of awareness of only 5% for the Defeat Depression Campaign in the UK.
Studies of modes of delivery other than mass media were not common, and were less
conclusive about changes in knowledge, attitudes and behaviour. There were,
however, indications that social contact with people experiencing mental illness may
be associated with improved community attitudes.

A number of recommendations may be made about the content and mode of delivery
of campaigns targeted to the whole of the community. Importantly, evaluations of
other health communication campaigns conducted in Australia and overseas have
found that messages are particularly well received when the positive outcomes of
attitudes or behaviours are communicated. With respect to mode of delivery, the
literature indicates that mass media campaigns may be most effective when
complemented by other more direct approaches, such as the dissemination of printed
materials or community activities. (See also Section 4)

While it may be concluded that mass media campaigns in particular are a potentially
effective approach to improving mental health literacy, it should be acknowledged
that such strategies are generally expensive, and none of the studies adequately
addressed the issue of cost-effectiveness. It is clear that further evaluation of mental
health literacy programs is required, particularly in the area of cost-effectiveness of
programs targeting the whole of community. There is often a tendency in planning
mass media campaigns to equate them with typical advertising campaigns and, as
discussed below in Section 4, this may well be an inappropriate strategy.

26
Table 1 - Whole of community programs

Investigators Audience Study Design Country Method Program Content Key Findings
Priest, Vize,
Roberts,
Roberts and
Tylee (1996)

Paykel, Tylee,
Wright, Priest,
Rix, Hart
(1997)

Paykel, Hart,
and Priest
(1998)
Whole of
community
Separate
samples pre-
test/post-test
study with no
concurrent
controls

United
Kingdom
Nationwide Defeat
Depression
campaign involving
wide range of
media conducted
1991-1996. Surveys
of 2000 participants
about public
attitudes towards
depression
conducted at
baseline (1991) and
follow-up (1995 &
1997)

Media activities included a
press conference and reports
of personal experience of
depression by several high
profile individuals.
Publications including
leaflets and books about
depression were produced
and disseminated widely.
Fact sheets were prepared in
different languages to reach
ethnic minority populations.
Audiocassettes and
videotapes promoting coping
techniques for people with
depression were produced.
Defeat Depression Action
Week was held in 1994,
involving media briefings
and community activities,
and further Action Days
were held in 1995 and 1996.

Community attitudes to
depression were positive
with little change over
the study period
Attitudes to treatment for
depression improved
over the study period
Very few participants
(5%) could recall the
campaign

27
Barker,
Pistrang,
Shapiro,
Davies, Shaw
(1993)
Whole of
community
Pre-test/post-
test study with
non-viewers
acting as
control group
United
Kingdom
Nationwide mental
health promotion
television series
You in Mind
screened in 1987.
Surveys of 1040
participants were
conducted at
baseline and at
follow-up 12
months later.

The television series, You in
Mind, comprised seven ten-
minute programs presenting
information about mental
health problems and
providing examples of
coping methods. The
programs were positive in
tone, and depicted ordinary
people describing coping
skills for common emotional
problems. The program titles
were: The Tranquiliser Trap,
Being Assertive,
Overcoming Insomnia,
Overcoming Fear,
Overcoming Depression,
Expressing Feelings, and
Change. A booklet was
available on request, and
provided supplementary
information about mental
health topics and details of
national and local mental
health services.

The series was viewed
by 13% of population
For those who viewed
series there was some
evidence of positive
impact on attitudes
towards people with
mental illness
Around 45% of viewers
stated that they had
changed or intended to
change their behaviour
in terms of coping with
their own problems

28
Medvene and
Bridge (1990)
Whole of
community
Pre-test/post-
test study with
no concurrent
controls
United
States
541 participants
viewed mental
health education
television
documentary in two
separate groups.
Participants
surveyed about
attitudes towards
mental illness prior
to and after viewing
program

A television documentary
was produced with the aim
of bringing the audience into
contact with individuals who
had been in psychiatric
hospitals. The content of the
film comprised personal
interviews with 14
individuals, who each
described their experiences
of community-based
treatment
Viewing intervention
program resulted in
improved attitudes
towards mental illness in
one of the study groups

29
Evans Research
(1999)
Whole of
community
Post-test only
study with
purposive
sampling and
no concurrent
controls
Australia Nationwide
Community
Awareness
Program was
launched in 1995,
comprising mental
health information
brochures.
Evaluation of the
program in 1999
involved surveys of
health
professionals,
mental health
organizations and
consumer groups.

The evaluated component of
the campaign included a
series of mental health
information brochures
covering the topics: mental
illness, stigma, the National
Mental Health Strategy,
depression, anxiety, eating
disorders, schizophrenia, and
bipolar disorder.
More than half of the
respondents had seen the
brochures
All brochures were
considered to be highly
useful
Recommendations were
made for development of
new materials, including
an expanded set of titles,
and the use of an
integrated brochure, CD-
ROM and web site
Recommendations were
made for improving the
distribution approach,
e.g. through
collaboration with State
and Territory health
departments

30
Fonnebo and
Sogaard (1995)

Sogaard and
Fonnebo (1995)
Whole of
community
Pre-test/post-
test study with
control group
at post-test
only
Norway Nationwide mental
health promotion
television program
broadcast in 1992.
Survey of 1191
participants was
conducted prior to
the campaign, and a
follow-up survey of
644 of the original
participants was
conducted one
month after the
broadcast.

The campaign comprised a
six-hour fund-raising
television program broadcast
nationwide. The program
included information about
mental health issues,
entertainment and fund-
raising activities. Prior to the
broadcast of the program,
newspaper and television
advertisements, and
educational television and
radio programs about mental
illness raised awareness of
the campaign. A campaign
newspaper was sent to every
household, and information
was distributed to
organizations including
community health centres,
schools, libraries and
psychiatric institutions. The
campaign was supported by
the government, the King
and Queen of Norway, and a
number of church
organisations. Community
activities were also organised
to coincide with the
campaign.

Approximately 94% of
participants were aware
of the campaign, and
62% had viewed the
television program
There were positive
changes in knowledge
and attitudes following
the campaign

31
Tolomiczenko,
Goering and
Durbin (2001)
Whole of
Community
After only
study with
non-
randomisation
of concurrent
controls and
two
intervention
groups

Canada 575 participants
selected from high
school students
attending a brief
educational
program.
Participants were in
one of three groups:
video, video plus
discussion, and
control.
Questionnaires
were completed
following the
program to measure
attitudes to mental
illness and
homelessness.

A video about mental illness
and homelessness, entitled A
Fine Line, was produced for
the program, and depicted
caseworkers, clients and
psychiatrists involved in the
Hostel Outreach Program in
Toronto, Canada. The
evaluation of the video was
conducted as part of a
regular public education
program. For the purposes of
the study, the regular
education program acted as
the control condition. The
program was varied to
provide two different
interventions: the video
intervention included the
video A Fine Line in place of
the video routinely used in
the program, and the video
plus discussion intervention,
utilised the video A Fine
Line along with a follow-up
discussion with a homeless
person.

Viewing the video
resulted in more
negative attitudes to
mental illness and
homelessness
The combination of the
video plus discussion
with a homeless person
resulted in some
improvement in
attitudes.
Direct contact with
people with people with
a mental illness was
associated with more
positive attitudes.
Recommendation that
educational media
messages about mental
illness and homelessness
should be targeted to
particular audiences

32
Wolff, Pathare,
Craig and Leff
(1996a)

Wolff, Pathare,
Craig and Leff
(1996b)

Wolff, Pathare,
Craig and Leff
(1996c)

Whole of
community
Pre-test/post-
test study with
non-
randomisation
of concurrent
controls
United
Kingdom
A survey of
attitudes to mental
illness was
undertaken in two
areas of South
London prior to the
opening of a
supported
accommodation
house for people
with mental illness
in 1993. An
education campaign
was conducted in
one area, and a
follow-up survey of
attitudes conducted
in both areas.

The education campaign
comprised three elements: a
didactic component,
consisting of an information
video and written material; a
social component, including
social events and social
interaction with staff; and a
mixed component, consisting
of a formal reception and
informal discussion
meetings. The campaign was
developed in consultation
with staff from the supported
accommodation houses.
Approximately one-third of
participants in the
intervention area agreed to
receive the educational
material.

There were some
improvements in
attitudes and behaviour
in the intervention area,
but only a small change
in knowledge
Social contact with
patients was associated
with less fearful attitudes
in the intervention area

33
Holmes,
Corrigan
Williams, Canar
and Kubiak
(1999)
Whole of
community
Pre-test/post-
test study with
non-
randomisation
of concurrent
controls
United
States
Education program
about severe mental
illness was
administered to 35
adult students
enrolled at a
community college.
A second group of
48 students in a
General Psychology
course acted as a
comparison.
Participants
completed Opinions
about Mental
Illness
questionnaire prior
to and following the
education program.

The program involved a
semester-long course about
severe mental illness, which
aimed to provide accurate
information and dispel
misconceptions about
schizophrenia. The course
provided information about
rehabilitation for people with
psychiatric disability. There
was discussion of the causes,
treatment and prognosis of
schizophrenia, and a review
of the evidence relating to
dangerousness. Presentations
were given by a mental
health consumer and a family
member, with the intention
of reducing negative
attitudes to mental illness
through direct contact.

There were some
positive changes in
attitudes in the
intervention group
following the program
A greater level of prior
knowledge and contact
with people with mental
illness mediated the
effects of the program

34
3. Review of individual studies - Programs targeted
to specific populations

A number of programs designed to improve mental health literacy have been directed
towards specific subgroups of the population, rather than to the general community as
a whole. Studies focusing on targeted mental health literacy programs are included in
this section of the review. The key findings from each of the studies are outlined in
Table 2.

Mental health literacy programs may focus specifically on certain groups within the
population who have a particular need for mental health education. For example, it
has been argued that lack of mental health literacy can create difficulties for families
and caregivers, and therefore mental health education targeted to these groups may
help to improve quality of life for people with mental illness (Pickett-Schenk, Cook et
al. 2000). Seven studies included in this review evaluated mental health education
interventions targeted to caregivers, and overall found beneficial effects. While it is
recognised that mental health consumers are themselves an important target group for
similar mental health education programs, it is important to note that no formal
evaluations of such programs were identified for inclusion in this review.

Adolescents are also recognised as an important target population for mental health
literacy and awareness programs. Programs targeted to adolescents are generally
delivered through schools, often by incorporating mental health issues into the school
curriculum, and sometimes through a whole-school approach, addressing the
opportunities for promoting mental health beyond classroom mental health education.
Five programs targeted to adolescents were identified for inclusion in this review, all
of which were delivered in school-based settings.

Other groups who may not otherwise be reached by more general community
programs, such as people from non-English speaking backgrounds, have also been
identified as important target audiences for programs to improve mental health
literacy. While several projects have examined the needs of people from different
cultural backgrounds (Delgado 1980; Meiser and Gurr 1996; Chien, Kam et al. 2001),
only one evaluation of a mental health literacy program targeted to these groups was
found for inclusion in the review.
Carers and families of people with mental illness
A number of studies have focused on education programs targeted specifically to
family members of people with mental illness. Pickett-Schenk, Cook and Laris (2000)
evaluated the mental health education program, J ourney of Hope, which was
developed by the National Alliance for the Mentally Ill (NAMI) in the United States
in 1993. The program aimed to provide education and skills to family members of
people with mental illness to assists in their role as caregivers. It comprised an eight-
week education course and a long-term support group. Participants were not required
to attend both parts of the program, and thus participated according to their own
perceived needs. The education course and support groups were conducted by
volunteers, who were all relatives of people with mental illness. Course instructors

35
and support group leaders received training from the National J ourney of Hope
Institute.

The evaluation aimed to investigate the outcomes for families who had participated in
the program from 1993 to 1996. Participants were given a series of questionnaires
after their participation in the program, which were designed to assess participation
level, satisfaction with the program, and achievement of program outcomes. A total of
1,131 participants were sent questionnaires about the program, and responses were
received from 424 individuals, giving a response rate of 39%. The majority of
respondents were female (79%), and were parents of a person with a mental illness
(65%). The relatives being cared for were predominantly male (67%), and most
frequently had a diagnosis of schizophrenia (42%). It was found that the
overwhelming majority of participants who responded to the questionnaire felt the
program had resulted in improvements in their knowledge of causes and treatment of
mental illness, their knowledge of the mental health care system, and their overall
morale.

The authors examined whether particular factors were predictive of achievement of
program outcomes. It was found that participants who expressed greater satisfaction
with the education program were more likely to report improved knowledge of both
mental illness aetiology and mental health services. It was also found that those who
were caring for a relative with a diagnosis of schizophrenia reported increased
knowledge of causes and treatments of mental illness, while those whose relatives did
not have schizophrenia tended to report improved morale as a result of the program.
Overall, the authors stated that the J ourney of Hope program may assist families to
cope in their role as caregivers, and proposed that the program may be appropriate for
offering education and support in future to families of people with mental illness.

An early study by Leff et al (1982; 1985) investigated the impact of a social
intervention for families of people with schizophrenia. The aim of the project was to
determine whether a social intervention could affect the course of schizophrenia in
individuals who were also on anti-psychotic medication. The social intervention
involved a brief educational program, a support group for relatives, and family
sessions held in the home. The educational component comprised two sessions, and
provided information about the causes, symptoms, prognosis and management of
schizophrenia.

The study design involved a randomised controlled trial, with 24 participants selected
from recent admissions to three London hospitals. All participants were aged from 16
to 65 years, had been living with relatives prior to admission, spent more than 35
hours per week in direct contact with at least one relative, and lived close to the
hospital of admission. In addition, at least one member of the family had been
identified as high expressed emotion, as the authors were interested in the impact of
expressed emotion on the course of schizophrenia. All 24 participants had been
prescribed anti-psychotic medication, and families were randomly assigned to either
the intervention or control group. Characteristics of both groups were found to be
similar, with the exception that the participants in the intervention group had
experienced significantly greater duration of unemployment prior to hospital
admission.

36
The social intervention was conducted with the intervention group for nine months,
and follow-up was conducted immediately after the program, and again at two-years
post-intervention. At two-year follow-up, it was found that a total of five participants
had discontinued their medication. Three of these participants were from the control
group, and the remaining two were in the intervention group. These participants were
excluded from the evaluation of the program, as the aim of the intervention was to
examine its impact in addition to regular pharmacological treatment. For the
remaining participants, it was found that there had been a relapse rate of 78% in the
control group, and only 20% in the intervention group. Relapses were defined as
either the reappearance of symptoms of schizophrenia or the exacerbation of
previously stable symptoms. The difference in relapse rate between the two groups
was statistically significant. It was also found, however, that a number of suicide
attempts had been made by participants, and when these were included in the rate of
treatment failure, there were no significant differences between the two groups.

The authors concluded that the social intervention had resulted in improved outcomes
for participants in terms of schizophrenic relapse. They acknowledged, however, that
this was not the case when suicide was included as a measure of management failure,
along with reappearance or exacerbation of symptoms of schizophrenia. It is
important to note that the authors did not attempt to measure whether the social
intervention had any impact on the knowledge, attitudes and behaviour of families
who participated, therefore it is unclear whether the educational aspects of the
program achieved changes in mental health literacy.

This particular issue was addressed in a later study by Berkowitz et al (1984; 1990),
which aimed to measure the impact of the educational aspect of the program
described by Leff et al (1982; 1985). The later study included 33 participants from 23
different families of people with schizophrenia, and inclusion criteria for participants
were similar to those in the earlier study by Leff et al. All participants undertook the
educational program, and were then randomly allocated to either a relatives group or
to family therapy for the remainder of the study.

The educational component comprised four brief presentations given by mental health
professionals about causes, symptoms, diagnosis, treatment and course of
schizophrenia. The content of the educational program remained the same as in the
earlier study, however the information was presented in a more personal manner.
Participants received the information in their homes, and each family was given the
presentations separately. Evaluation of the educational program involved interviews
with participants, which were designed to measure changes in knowledge. Interviews
were conducted prior to the program, immediately following the education
component, and again nine months later. Of the 33 participants, 21 completed all three
interviews, and only these complete data sets were included in the analysis.

It was found that responses to several questions changed significantly over the course
of the education program. In particular, there were increases in the number of
participants who knew what was wrong with their ill relative and could name the
condition. At nine-months follow-up, significantly more participants stated that
schizophrenia could be inherited, family members attitudes to the ill relative had
improved, and there was increased optimism for the future of ill relatives. It was

37
found that there were no significant differences in knowledge between participants in
the relatives group and those in the family therapy group.

It was concluded that the changes in knowledge measured immediately following the
program could most likely be attributed to the impact of the educational component.
The authors stated that the changes identified at the nine-month follow-up might have
been influenced by the therapeutic interventions in addition to the education program.
In contrast to the previous study, the authors were able to demonstrate that the
educational component of the program had an impact on knowledge. They
acknowledged that immediate changes in knowledge were limited and were largely
related to diagnosis, however they argued that initial changes may have enabled
families to develop greater tolerance for their ill relatives and to continue improving
their knowledge.

A similar program for families of people with schizophrenia was evaluated by Smith
and Birchwood (1987). The evaluation focused on the benefits of an educational
program for relatives and mental health consumers, and measured changes in
knowledge and perceptions of schizophrenia. Participants in the study were 23
families who had a relative with schizophrenia, and who were selected using a
random sample of patients with schizophrenia from a hospital in Birmingham.
Patients who were selected for the study all had one or more major symptoms of
schizophrenia, were either living at home or in close contact with their family, and
had been prescribed neuroleptic medication. Participants from the 23 families were
randomly assigned to one of two intervention groups.

The first group was designated the group condition intervention, and received an
educational intervention consisting of four information sessions conducted by a
therapist over a four-week period. The sessions were in a seminar format, and
included oral and audiovisual presentations, as well as general question and answer
discussions. Participants also received a booklet containing information covered in
each session and a written homework exercise. The second group, referred to as the
postal condition intervention, received only the information booklet and the
corresponding homework exercise through the post each week over the four-week
period. Information given to both groups was divided into four sections, comprising:
concepts and causes of schizophrenia, symptoms of schizophrenia, treatments and
prognosis, and hospital and community resources.

Evaluation of the program involved measures of knowledge, beliefs, worry and fear,
behavioural disturbance, stress and family distress. Measurements were taken prior to
the commencement of the program, immediately following the intervention, and again
at six-months follow-up. It was found that there were no significant differences
between the two intervention groups at baseline on any of the measures, with the
exception that the participants in the postal group had a significantly higher level of
worry.

Following the program, there were significant improvements in knowledge in both
groups, which were maintained after six months. However, it was found that group
condition participants gained significantly more knowledge than postal condition
participants. Participants in the two groups indicated similar beliefs about the
treatment and course of schizophrenia throughout the study, however immediately

38
following the intervention the group condition participants indicated increased
optimism about the role of the family in treatment compared with the postal group.
This difference disappeared at six-months follow-up.

In terms of measures other than those relating to knowledge and beliefs, it was found
that levels of fear decreased for both groups following the intervention. At six-month
follow-up this change was only maintained in the postal group. Scores for levels of
stress also decreased for both groups immediately following the intervention, however
this was not maintained in either group after six-months, when it was found that
scores had returned to baseline levels. Levels of reported burden on the family did not
change immediately following the intervention, however for both groups there were
significant reductions in this measure at six-months follow-up. Scores for symptom
related behavioural disturbance in the family members with schizophrenia did not
alter in either group throughout the study.

Overall, the findings of the study indicated that the educational intervention had
resulted in significant improvements in knowledge and reductions in stress and fear
among participants. However, no association was found between levels of knowledge
attained and measures of other effects on family members. After six months, only the
changes in knowledge were maintained, and all other effects had returned to baseline
levels, with the exception that participants in the postal group maintained reductions
in levels of reported fear. The authors stated that the information presented to
participants in both groups had resulted in increased knowledge, however knowledge
acquisition was enhanced in the participants who were presented with the educational
information in group sessions. Most other effects of the intervention were common to
both groups, which indicates that the information content itself was responsible for
these changes, rather than the mode of delivery. The authors stated that the study had
shown that access to written information was an effective and less costly alternative to
group education. They acknowledged, however, that such an approach lacked
flexibility for adaptation to individual needs and did not provide opportunities for
feedback and clarification.

Solomon et al (1996) conducted a randomised controlled trial to investigate a similar
program for relatives of people with serious mental illness. Two different
psychoeducational strategies were selected for the program: group psychoeducation
and individualised consultation. The program was broader than those investigated in
previous studies in that it sought to include family members regardless of whether the
ill relative was residing with the family or was seeking treatment. The study therefore
aimed to measure the impact on family members of interventions that were
independent of the treatment or participation of ill relatives. The two interventions
compared in the study were developed by family advocates and mental health
professionals, and were administered by the Training and Education Center (TEC)
Network. Investigations in the current study involved measurement of the impact of
the interventions on participants in terms of subjective burden, grief, social support,
self-efficacy, mastery, adaptive coping, and stress.

The study was conducted in a city on the east coast of the US, and participants were
recruited through support groups, hospital social service departments, family
information programs, and media presentations. Individuals asked to participate in the
study were relatives of people who had been diagnosed with either schizophrenia or

39
major affective disorder at least six months prior to the study. Participants were
required to have major responsibility for and be in regular contact with the ill relative,
and participants and ill relatives were all at least 18 years of age. A total of 225
participants were recruited for the study and were randomly allocated to one of three
groups: 66 were assigned to individual family consultation, 67 to group family
psychoeducation, and 92 were allocated to a waiting list, which acted as the control
group.

Interventions were conducted over three months, and participants were surveyed prior
to and following the intervention period. The individual family consultation
intervention involved between six and fifteen hours of educational assistance provided
by a specialist consultant to either the whole family or one family member. Group
family psychoeducation comprised ten two-hour sessions, which were delivered to
participants in eleven separate groups, and were facilitated by trained mental health
specialists and peer consultants.

Following the intervention period, it was found that the only significant outcome
associated with the interventions was an improvement in specific self-efficacy.
Specific self-efficacy was defined as confidence in ones ability to understand a
relatives mental illness and cope with its consequences. The authors stated that this
finding was not unexpected, as the psychoeducational interventions tended to focus on
improving family members confidence in relating to their ill relatives. Further
analysis was conducted to determine whether prior experience in support groups had
an impact on outcome of the interventions in terms of specific self-efficacy. It was
found that individual consultation resulted in improved self-efficacy regardless of
prior support group attendance, while group psychoeducation was beneficial only to
those who did not have previous support group experience.

It was concluded that, while both psychoeducational interventions had demonstrated
improvements in self-efficacy among participants, individual consultation was more
useful than group psychoeducation for those who had previously attended family
support groups. The authors noted, however, that individual approaches involve
greater resources than group strategies. They therefore concluded that it might be
appropriate to adapt group psychoeducational sessions to involve components of the
individual consultation model, such as focusing on providing empathy and support to
individual group members.

In contrast to the previous studies, which examined educational programs for general
family members, Mannion, Mueser and Solomon (1994) studied the impact of a
program designed specifically for spouses of people with severe mental illness. The
program involved a group psychoeducational approach, and comprised ten two-hour
sessions conducted over consecutive weeks. As in the previous study (Solomon et al
1996), the program was administered by the Training and Education Center (TEC)
Network. The program was developed following collaboration between mental health
professionals and a number of spouses of people with mental illness who had
previously attended coping skills workshops at the TEC. Each of the ten sessions was
facilitated by a mental health professional and a trained family member, and involved
a 30-minute oral presentation followed by a 90-minute discussion of coping skills.
Participants also took part in role-play exercises, and were provided with written
material and homework tasks.

40

The aim of the evaluation was to measure whether the program improved knowledge
of mental illness and coping strategies. A questionnaire was developed for the
purposes of the study, and was administered prior to and following the program, and
at one-year follow-up. The questionnaire included items about attitudes to the ill
partner and levels of personal distress, as well as questions relating to knowledge of
mental illness and coping skills. A total of 34 participants who took part in the
program were involved in the study, however only 19 (68%) completed
questionnaires prior to and immediately following the program. Of these participants,
10 (53%) completed the one-year follow-up assessment.

The results of the questionnaire administered prior to the program indicated that high
levels of personal distress were significantly associated with negative attitudes to the
ill spouse. Following the program, it was found that there were statistically significant
improvements in participants knowledge of mental illness, coping skills, levels of
personal distress and attitudes to the ill partner. These improvements were maintained
twelve months after the program. Analysis of the results showed that reduced levels of
distress were associated with improved attitudes to the spouse. However, it was found
that changes in knowledge and coping skills were not related to improved levels of
distress or attitudes to the ill partner.

The authors concluded that the program had been effective in improving participants
knowledge and coping skills, while reducing levels of distress and negative attitudes
to the ill spouse. However, they also stated that improved knowledge and coping
skills were not directly related to observed changes in distress and attitudes. It was
hypothesised that social support attained from the intervention may have been
responsible for reduced distress and more positive attitudes. The authors argued,
however, that improving knowledge of mental illness was an important goal of spouse
educational programs, as this may lead to improved ability to monitor symptoms and
management of the illness.

A mental health education program specifically for caregivers of elderly people with a
mental illness was evaluated by Raskin et al (1998). The study involved 20 caregivers
at community residences in the United States who were providing care to a total of 63
veterans aged 55 years or older. The education program comprised two sessions
conducted over two weeks. Each session ran for two hours, and presenters included
mental health and allied health professionals. Presentations included information
about the causes, symptoms and treatment of major mental illnesses, and the provision
of support and care for the elderly residents. In addition to the presentations,
participants in the program received an information manual, providing an overview of
symptoms and treatment of mental illness, and focusing in particular on issues
relating to the elderly.

The program was evaluated using assessment instruments designed by the authors to
determine the impact of the training sessions on the elderly residents. Following the
program, participants were asked to rate the usefulness of the program, and a follow-
up survey one year later was designed to provide information about the experiences of
the residents who were looked after by the caregivers.

41
Information collected prior to the program indicated that the residents involved in the
study were generally single, white males with a mean age of 66 years. The vast
majority (82%) had a diagnosis of schizophrenia. Living conditions were rated
positively overall, and 91% of the residents had previously been hospitalised.
Following the program, the majority (70%) of caregivers who had participated in the
program indicated that they found it helpful. In particular, the information provided
about mental illness and treatments was well received by participants, and the vast
majority (88%) enjoyed the opportunity of meeting with other caregivers.

At the one-year follow-up, it was found that there was a significant decrease in the
number of hospital admissions for the 63 residents during the twelve months
following the program (26 admissions), when compared with the twelve months prior
to the program (37). The majority of hospital admissions which occurred in the year
following the program were for medical reasons (17) rather than psychiatric reasons
(9), however those admitted for psychiatric reasons generally spent more time in
hospital than those admitted for medical reasons. It was found that there were few
changes in living arrangements for the residents in the year following the program.
There was, however, some improvement in terms of the number of quality of life
activities for the residents.

The authors concluded that the education program served a useful purpose for the
caregivers who participated, and that hospital admissions for the elderly residents
decreased following the program. They also stated that the individuals with mental
illness who were involved in the study were happy with their living arrangements, and
that they were able to develop positive relationships both with caregivers and with
other residents in the home. The authors argued that these findings provided support
for the policy of placing people with chronic mental illness in community residences.
School-based programs for adolescents
Two studies conducted in Australia have considered the impact of school-based
mental health literacy programs targeted to adolescents. A recent evaluation of the
MindMatters pilot project in Australia identified a number of positive outcomes,
although the overall findings were mixed (MindMatters Evaluation Consortium 2000;
Wyn et al. 2000). The MindMatters pilot project was undertaken in 1998 and 1999 in
24 schools selected from all Australian states and territories. The aims of the project
were to improve attitudes, values and knowledge of mental health, improve life skills
capabilities among young people, improve access to mental health resources, and
promote models of excellence in mental health promotion in schools. The project
involved the development of resources for a whole-school approach to mental health
promotion, and was based on the Health Promoting Schools concept (Commonwealth
Department of Health and Family Services 1996). This approach included
incorporating mental health education into the school curriculum, as well as
addressing school policies and practices.

At the beginning of the program, teachers were provided with two days of
professional development activities, in order to introduce the concepts of Health
Promoting Schools and MindMatters. Each of the schools involved in the project then
established a core team, who were responsible for planning and implementing the
project. At the beginning of the project, schools conducted an audit of their current
mental health curriculum and activities, then utilised the MindMatters resource

42
documents to implement strategies that addressed their particular needs. Classroom
resources developed for MindMatters related to four key issues: enhancing resilience,
understanding mental illness, bullying and harassment, and loss and grief. Each
school agreed to incorporate at least one of the curriculum units into their educational
program. Schools also developed a range of activities as part of their whole-school
strategies, which included youth forums, mental health days, producing plays and
videos, and conducting staff surveys about mental health issues. Schools were also
encouraged to form partnerships with community organizations and health agencies to
enhance the whole-school approach to mental health promotion.

Following the project, an evaluation study was undertaken involving qualitative and
quantitative methods. One of the key aims of this study was to measure outcomes for
students involved in the program in terms of changes in knowledge and attitudes to
mental health, quality of school life, and coping style. Students were administered a
Knowledge and Attitude questionnaire, developed for the project. They were also
given the Quality of School Life Questionnaire, to assess changes in perceptions of
school life, and the COPE questionnaire, which is designed to measure coping styles.
Questionnaires were administered at baseline, during the project, and following the
project. It should be noted that incomplete data sets were received from six of the
schools, and a further five schools did not provide any data from the questionnaires.

It was found that, although all schools implemented at least part of the curriculum
resources, there was a lower level of commitment to introducing changes in school
ethos and developing new community partnerships. With respect to the curriculum,
the most frequently utilised resources related to Dealing with Bullying, with
eighteen schools incorporating this into the curriculum. In addition, twelve schools
used Understanding Mental Illness, ten schools used Enhancing Resilience, and
only four schools trialled the Loss and Grief curriculum.

Evaluation of student outcomes indicated that there was in fact a decrease in the
proportion of students who could define mental health in health-related terms, and a
decrease in the proportion of students who could correctly name one mental illness,
following the project. In contrast, there was a significant increase in the proportion of
students who stated that they would be willing to have someone with a mental illness
marry into their family, or to have someone with a mental illness as a teacher. There
was no change in the proportion of students who nominated school as a source of
information about mental illness throughout the project. There was found to be an
increase in the proportion of students who were willing to seek help from professional
sources, but no change was found in the proportion of students indicating that they
used a range of coping styles.

The authors concluded that they were unable to address the issue of causality in terms
of changes in students knowledge and attitudes as a result of the project. It appears,
however, that changes in knowledge, attitudes, and behavioural intentions did not
follow any particular trend. The authors argued that a number of beneficial outcomes
of the project were identified. In particular, there had been uptake of at least part of
the curriculum components in all schools, and the implementation of the program had
been supported by the participating schools. They stated that the pilot project had
been most successful in schools where there was support from the school executive

43
and the school community, and recommended that the implementation model be used
for future projects.

An earlier evaluation of school-based mental health education looked at the School
Education Program (SEP) now known as Mental Illness Education Australia
(MIE-A) - which was an initiative of the New South Wales branch of the Association
of Relatives and Friends of the Mentally Ill (ARAFMI) (Wearing and Edwards 1994).
The aim of the SEP was to educate school students nationwide about mental health
and mental illness, in order to improve understanding and reduce fear and ignorance
of mental illness among young people and their families. The program, which began
in Sydney in 1988, received funding from the Australian Youth Foundation in 1992 to
extend its activities nationwide, and had commenced in other states by 1994.

In contrast to the MindMatters program, the educational component of the SEP
involved presentations given to school students by volunteers with experience of
mental illness. Topics covered in the presentations included: definitions of mental
illness, facts and statistics, community attitudes, personal experiences of mental
illness, and a discussion of mental health resources available to students. A range of
curriculum materials were developed to promote the program and to assist the
classroom presentations. These included fact sheets, information packs for teachers, a
video, and orientation kits to help with recruitment of volunteer presenters.
Volunteers were trained in order to enhance skills in presentation techniques, as well
as knowledge of mental illness, and presenters underwent ongoing review throughout
the program. The program content and format were also revised and improved
between 1992 and 1994, in order to focus more on the concept of the relationship
between mental illness and mental health. In addition, a program for students from
Non-English Speaking Backgrounds (NESB) was developed to address the particular
needs of this audience.

The evaluation of the program aimed to assess the impact of the SEP on students.
Surveys of students were conducted at two stages during the program. The first survey
was undertaken prior to the education program, and involved 162 young people in the
Sydney area. This results of this survey indicated that the vast majority of respondents
(98%) had a medium level of general understanding of mental illness prior to the
educational program. The authors also noted that 36% of participants reported
previous contact with someone with a mental illness. A second survey was conducted
nationwide after May 1994, however only 25 further responses were obtained in
addition to the initial Sydney-based sample, and all of these were from students in
Queensland. It was found that there were improvements in awareness of mental
illness following the education program, and those with prior direct contact with
mental illness were more likely to show improved attitudes following the program
than those with no previous exposure. It is important to note, however, that measures
of statistical significance of changes in knowledge were not provided.

The authors concluded that the SEP had been effective in generating greater
awareness of mental illness among participants. They stated that the role of volunteer
presenters was an important factor in the success of the program. The authors argued
that there was a need to target the program to particular audiences, as the student
population is diverse in terms of cultural and socio-economic backgrounds. They also
stated that it was important to recognise when structuring the program that a

44
significant proportion of young people will have prior experience of or contact with
mental illness. It is worth noting that, since the evaluation was conducted in 1994, the
School Education Program (now MIE-A) has undergone considerable revision, and
evaluations of the revised program are currently in progress in a number of Australian
states and territories.

In the overseas context, a school-based program to improve understanding of mental
health issues undertaken in a rural area of Pakistan found encouraging results
(Rahman et al. 1998). The aim of the program was to improve the awareness of
school students, as well as their parents, friends and neighbours, of issues relating to
mental health and illness. Four schools were selected to participate in the study. Two
of the schools were involved in the intervention program, and the remaining two
schools acting as control groups. All four schools had similar characteristics in terms
of size and socio-economic areas, and all were government run. Participants in the
study were 100 school students (aged 12-16 years), 100 parents, 100 friends who did
not attend school, and 100 neighbours.

The educational program was facilitated in each school by a mental health team
comprising a doctor, a psychologist and a social worker. The teams first assessed each
schools educational facilities, as well as the knowledge, attitudes and behaviour of
teachers with respect to mental health issues. Teachers attended training courses about
mental health disorders, and collaborated with the mental health team in developing
the educational curriculum for the school. Educational methods devised for the
program included essay writing and poster competitions relating to mental health, and
the production of short plays. During the program, teachers gave daily lectures about
mental health issues to the students, and mental health posters were displayed in
schools. The mental health teams also made weekly visits to the schools.

The evaluation involved an assessment of attitudes to and awareness of mental health
issues before and after the school program. Participants were given a 19-item
questionnaire designed to assess knowledge and attitudes to mental health disorders.
A high score on the questionnaire indicated a high level of awareness of mental health
issues. School students were administered the questionnaire in the classroom, and
were then given three additional questionnaires in order to collect responses from a
parent, a friend who did not attend school, and a neighbour. The questionnaire was
given to all participants prior to the start of the school program, and again after
completion of the program.

Prior to the beginning of the program, levels of awareness were found to be poor
overall. Scores were particularly low for questionnaire items relating to traditional
beliefs about mental illness. For example, respondents tended to agree with statements
suggesting that people with a mental illness are dangerous, immoral and a bad omen
for the family. School students in both the control and intervention groups received
similar scores on the questionnaire conducted prior to the beginning of the program.
This was also true for parents and friends who completed the questionnaire, but the
neighbours in the control group received slightly lower scores than neighbours in the
intervention group.

All intervention groups showed improvement in scores in every item after the
program, with the most significant change occurring in the school students who took

45
part in the program. Students in the intervention group scored significantly higher on
the questionnaire at the completion of the program than students in the control group.
In addition, parents, friends and neighbours of participants in the program all scored
higher than their counterparts in the control group. Although there was some
improvement in scores in the control groups of school students and their friends, this
was a much smaller change than that of the intervention group.

The authors stated that there was a significant improvement in participants awareness
of issues relating to mental health and illness following the four-month education
program. There was also found to be a significant improvement in the awareness of
their parents, friends and neighbours, however this change was less marked than that
of the school students who participated in the program. By comparison, only a minor
change in awareness was detected in the control groups throughout the study. The
authors concluded that the school program had been successful in improving mental
health awareness of the school students and their local community, and stated that this
model may be appropriate for other communities. They acknowledged, however, that
no long-term follow-up had been attempted, and they were therefore unable to
demonstrate a sustained change in attitudes or behaviour.

Esters, Cooker and Ittenbach (1998) similarly studied the impact of a mental health
education program on the knowledge and attitudes of rural adolescents, this time in
Mississippi. The study involved 40 students from a rural high school who were placed
into either an intervention or control group. The education program was presented to
the 20 students in the intervention group over three days. The program involved the
use of an educational video targeted to adolescents. Information was also provided
about sources of help in the community, including the definitions and qualifications of
different mental health workers, and there was discussion of the stigma associated
with mental illness. The control group attended regular classes, which did not cover
topics related to mental health issues.

The study involved the measurement of knowledge and attitudes relating to mental
illness prior to the education program, and on two occasions following the program.
Participants were given the Opinions about Mental Illness Questionnaire to measure
perceptions about mental illness, and the Fischer-Turner Pro-Con Attitude Scale to
measure attitudes to seeking help for mental health issues.

The results of the study were that the knowledge and attitudes of the intervention
group improved following the education program, and these changes were statistically
significant. It was also found that the changes were maintained at the three-month
follow-up survey. By comparison, the control group did not show any significant
changes on the questionnaire scores throughout the study. The authors concluded that
the intervention had successfully altered the participants knowledge of mental illness
and attitudes to seeking help for mental health problems. They argued that such
changes in attitudes were important in encouraging appropriate help-seeking
behaviour.

Similar results were obtained by Battaglia, Coverdale and Bushong (1990) in their
study of a school program coinciding with Mental Illness Awareness Week. The aim
of the study was to measure participants attitudes to seeking help for mental health
problems, and to measure their interest in receiving information about mental health

46
issues. The program comprised mental health information sessions presented to
students at a number of public schools. Presentations were given by psychiatric
physicians, and covered topics including psychiatry, depression, suicide, and drug and
alcohol issues. Twenty physicians from the psychiatry program at the University of
Texas were selected to give the presentations, and attended training sessions in
preparation. Presenters were also provided with manuals detailing available youth
services, which were distributed to the participating schools.

Participants in the program were 1,380 students from ten different schools who
attended a 45-minute presentation and who subsequently completed questionnaires. A
further 280 students selected from the same schools who did not attend the
presentations comprised the comparison group. Of those who took part in the
program, 57% indicated that they liked the presentation very much, and 69% found
that it was helpful. Similar numbers of students in both the intervention and
comparison groups indicated that they had previously received talks about mental
health issues at school, with just over one-third indicating that they had been
presented with a talk about psychiatrists and approximately half reporting that they
had received information about depression and suicide. Attitudes to mental health
professionals were generally positive in both intervention and comparison groups,
however those in the intervention group expressed more positive attitudes than those
in the comparison group. In addition, those who had previously received information
at school about psychiatrists were more positive than those who had not.

When asked about attitudes to help-seeking, those who had previously received
information about mental health issues were more likely to report that they would
seek help for mental health problems than those who had not received such
information. Out of all participants who indicated they had previously received mental
health information at school, those in the intervention group were more likely than
those in the comparison group to report that they would seek help for mental health
problems. An additional finding was that students in higher grade levels were
significantly less likely to report that they would seek help. J ust over two thirds (68%)
of participants in the intervention group indicated that they would like to receive
further information about mental health issues, compared with 58% of the comparison
group.

The authors concluded that the school presentations had a positive impact on
participants attitudes to mental health professionals and to seeking help for mental
health problems. This is consistent with the finding of Esters, Cooker and Ittenbach
(1998) that the presentation of mental health information to school students was
associated with more positive attitudes to seeking help. However, the authors of the
current study acknowledged that they were unable to determine whether positive
attitudes were maintained in the longer term.
People from non-English speaking backgrounds
A pilot study of the impact of a mental health literacy program targeted to people
from particular non-English speaking backgrounds was conducted as part of the
Defeat Depression campaign in the UK (Bhugra, Baldwin and Desai 1997). The aims
of the study were to determine whether the provision of fact sheets could improve
knowledge about depression, and to investigate the impact of participation in a
discussion group about depression.

47

The study involved the use of educational fact sheets produced in several languages:
Hindi, Punjabi, Gujarati, Bangla and Chinese scripts. The aim of the fact sheets was to
provide information about depression to the lay public, including descriptions of
symptoms, causes and treatment of depression. Participants in the study were people
who attended a drop-in centre in an area of West London, all of whom identified
themselves as originating from the Indian subcontinent. Of the 24 individuals who
attended the centre, 22 agreed to participate in the study. The sociodemographic
characteristics of those who agreed to take part in the study were found to be similar
to those of the individuals who declined to participate.

The study involved the use of the Depression Knowledge Questionnaire, which was
adapted from a questionnaire developed for use in the Defeat Depression campaign
population surveys (Priest et al 1996). Participants were asked to complete the
questionnaire about knowledge of depression at the beginning of the study. Fact
sheets were then distributed to each participant in their preferred language, and
questionnaires were re-administered following the presentation of the educational
information. This stage of the study was then followed by a twenty-minute discussion
about depression between the researchers and the participants, and questionnaires
were then administered for a third time following the discussion group.

Of the 22 participants, 21 provided complete sets of data for the study. Only these 21
data sets were included in the analysis of results of the study. Participants ranged in
age from 30 to 71 years, and the majority (12 participants) were women. The results
of the questionnaire administered to participants at the beginning of the study were
compared with those obtained in a survey of the general population conducted for the
Defeat Depression campaign (Priest et al 1996; Paykel et al 1998). It was found that
there were some differences in responses to the questionnaire between the study group
and the general population. For example, only 52% of study participants agreed that
depression is a medical condition like any other, compared with 73% of the general
population. The authors stated that this finding was expected, as previous surveys of
people from similar cultural backgrounds to the study group had shown that they did
not tend to have a medical model and explanation for the concept of depression.

After the presentation of the educational fact sheets, it was found that there was some
improvement in knowledge of depression among study participants. An example of
this was an increase in the proportion of participants who agreed that depression was
like any other medical illness from 52% at baseline to 66% following presentation of
the fact sheets. Participants views about treatment of depression also changed during
the study. The proportion of participants who agreed that anti-depressant drugs should
be offered as treatment for depression increased from 38% at baseline to 67% after
reading the educational information. It was also found that changes in knowledge
were generally maintained or improved following the discussion group. However, it is
unclear from the analysis of the data if the observed changes were statistically
significant, particularly given the small sample size.

The authors concluded that the provision of educational fact sheets in appropriate
languages had improved knowledge of depression among individuals from non-
English speaking backgrounds. They also stated that small-group discussions could
enhance changes in knowledge. They noted, however, that the study had been unable

48
to indicate whether such changes were maintained over time. It was also concluded
that there was a need to identify appropriate concepts and explanations of depression
for different cultural groups when developing future targeted programs.
Methodological issues
Research investigating programs targeted to carers and families of people with mental
illness raised several methodological issues. In their respective studies of mental
health education programs for caregivers, Raskin et al (1998) and Pickett-Schenk,
Cook and Laris (2000) did not use a control groups for comparison with the
intervention group. In addition, participants levels of mental health literacy were not
measured prior to the program; therefore neither study was able to demonstrate that
there were changes in knowledge or attitudes over the course of the intervention.

Raskin et al (1998) stated that measuring the impact of an educational program
targeted to caregivers was an important aim of their study, however the study design
was not appropriate to determine whether the program actually resulted in
improvements in knowledge. Although the findings indicated that there were
improvements for the residents who were being looked after by the caregivers, it is
unclear whether this was a direct impact of the program, or whether other factors may
have been involved. The study by Picket-Schenk, Cook and Laris (2000) of the
J ourney of Hope program relied on self-report of changes in knowledge, therefore it is
not known whether such changes actually occurred, and whether any reported changes
were due to participation in the program. It is also important to note that the response
rate to the survey was quite low (39%), and it is possible that those who did not
respond to the survey may have expressed different opinions about whether the
program outcomes had been achieved. The authors stated that a before-and-after study
design, with pre-test and post-test measures, would be needed to determine whether
the program outcomes were achieved. Given these limitations, it is unclear to what
extent the positive results reported in either study were actually achieved among study
participants.

Solomon et al (1996) used a randomised controlled trial study design to compare the
impact of two different educational interventions. This design does not share many of
the weaknesses of other studies of similar programs. It was possible in this study to
demonstrate the positive effects of the interventions, compared with a control group
who did not receive an intervention over the study period. Leff et al (1982; 1985)
similarly conducted a randomised controlled trial, and concluded that their study had
found a positive impact on the level of relapse for participants as a result of a social
intervention. Although the intervention and control groups were not entirely similar,
the authors stated that when the sample of participants was stratified by demographic
characteristics, no significant associations were found between these characteristics
and observed outcomes. However, the authors acknowledged that they could not
determine whether the impact of the intervention was due to the components of the
intervention itself, or to the increased attention given by professional staff to families
in the intervention group, as those in the control group did not receive the same level
of contact. They acknowledged that there are difficulties in providing placebos for
social interventions, and recommended that further research was necessary to
determine the impact of the specific aspects of such interventions.

49
This limitation was overcome to some extent by Smith and Birchwood (1987), who
examined whether educational information itself had any impact for families, rather
than the increased involvement of professional staff. They compared two different
interventions, and found that both the educational information and the context of its
delivery contributed to changes in knowledge. Berkowitz et al (1984; 1990) were also
able to measure the impact of the educational component of a program. However, the
study did not involve the use of a separate control group for comparison with the
educational intervention, and the authors acknowledged that the numbers of
participants in the two social intervention groups may have been too small for
meaningful analysis of the impact of the interventions on knowledge.

This issue was also raised by Bhugra et al (1997), who acknowledged that the small
sample size included in their study was an important limitation. The study also did not
involve a control or comparison group, and it is unclear whether the participants were
a representative sample of the particular cultural groups targeted by the program. As
this was a pilot study, the conclusions provide an indication only, and given the
studys limitations any findings may not be generalisable to other populations and
settings. It is important for similar studies to be conducted on a larger scale to confirm
the findings. In particular, future studies should consider whether any observed
changes are maintained in the longer-term.

Studies investigating the impact of school-based programs for adolescents also raised
particular methodological issues. In particular, the evaluation of the MindMatters
project faced a number of significant limitations (MindMatters Evaluation
Consortium 2000). The study did not involve the use of comparison schools, and the
authors acknowledged that true baseline data from the intervention schools could not
be obtained, as many of the schools had commenced the program prior to the first
round of data collection. Several schools were unable to provide complete sets of
responses to all three questionnaires, which made comparison between overall
baseline and follow-up data difficult to achieve. In addition, each school adopted a
different approach to implementation of the program, and therefore participants at
different schools received different interventions. As a result of the methodological
limitations of the study, the authors were unable to address the issue of causality in
relation to changes in knowledge and attitudes. It is clear that further evaluation
would be required to determine the impact of the program.

Similarly, the evaluation of the School Education Program (SEP) was unable to
provide adequate information about whether the program had resulted in changes in
knowledge and attitudes (Wearing and Edwards 1994). The authors of the evaluation
acknowledged that the sample was not representative of the participants in the
program, particularly in the second phase of the evaluation, which obtained a response
rate of only 10%. They were also unable to determine whether changes in awareness
of mental illness identified in the study were statistically significant, and stated that
the surveys were insufficient to detect changes in attitudes and knowledge. As this
was one of the important aims of the evaluation, the inability of the study to measure
such changes is a significant limitation of this particular study.

Unlike the MindMatters and SEP evaluations, the study by Esters, Cooker and
Ittenbach (1998) used a concurrent control group. Although the study did not involve
randomisation of participants into treatment and control groups, it was found that the

50
baseline questionnaire scores were similar for both groups. Battaglia, Coverdale and
Bushong (1990) similarly did not use randomisation in their study, and it is also
important to note that participants attitudes were not measured at baseline. It is
therefore unclear whether both groups in this study held similar attitudes prior to the
intervention. The authors acknowledged that the less positive attitudes to psychiatrists
expressed by the comparison group may have been due to prior negative bias amongst
the students who did not attend the presentations. The groups also had different
characteristics in terms of grade levels, and the comparison group was much smaller
than the intervention group, which meant that certain sub-groups were too small for
meaningful comparison.
Summary
Overall, the literature suggests that programs targeted to specific groups within the
population can improve levels of mental health literacy. It is important to note that
there were significant methodological limitations associated with many of the studies
reviewed in this section, and the generalisability of the findings is limited. The
strongest evidence perhaps relates to the impact of educational interventions for
families of people with schizophrenia. In addition to changes in knowledge and
attitudes, the literature indicates that programs targeted to carers and families of
people with mental illness may result in improved outcomes for mental health
consumers, however it is unclear whether such effects may be maintained in the
longer term.

Evaluations of school-based programs targeted to adolescents generally found
improvements in terms of awareness and attitudes relating to mental health issues.
While these results may be considered encouraging, it should be noted that the
evaluations of both the MindMatters curriculum and the School Education Program in
Australia were unable to address adequately the issue of changes in participants
levels of mental health literacy.

The nature of the literature indicates that there is a need for further evaluations of
programs targeted to subgroups of the population, particularly in the Australian
context. It is clear that there are various groups within the community who may
benefit from targeted mental health literacy programs, however there is little literature
addressing the issue of effectiveness of such programs at present. It is particularly
important that programs currently underway or in development undergo systematic
evaluation, in order to extend the evidence base in this area.

51
Table 2 Programs targeted to particular populations

Pickett-
Schenk, Cook
and Laris
(2000)

Carers and
families
Post-test only
study with no
concurrent
controls
United
States
Evaluation of the
J ourney of Hope
mental health
education program,
targeted to families
of people with
mental illness.
Questionnaires
given to
participants after
the program to
determine whether
program outcomes
had been achieved.
A total of 424 out
of 1,131
participants (39%)
responded to the
questionnaire.

The program comprised an
eight-week education course
and a long-term support
group, and was designed to
provide education and skills
to primary caregivers.
Participants were not
required to attend both parts
of the program. The
education course and support
groups were conducted by
volunteer family members of
people with mental illness
who received training from
the National J ourney of Hope
Institute.
The majority of
respondents reported that
the program had
improved their
knowledge and overall
morale

52
Leff, Kuipers,
Berkowitz,
Eberlein-
Vries, and
Sturgeon, D
(1982)

Leff, Kuipers,
Berkowitz
and Sturgeon
(1985)

Carers and
families
Pre-test/post-
test study with
randomisation
of controls
(randomised
controlled
trial)
United
Kingdom
Brief educational
program and longer
term support group
provided to families
of 24 people with
schizophrenia.
Participants were
randomly assigned
to intervention and
control groups.
Measurements of
relapse rates were
taken immediately
after the
intervention and
again at two-years
follow-up.

The social intervention
involved a short-term
educational program, a
support group for relatives,
and family sessions held in
the home. The educational
component comprised two
sessions, and provided
information about the causes,
symptoms, prognosis and
management of
schizophrenia. The program
was conducted over nine
months.
Relapse rates for
symptoms of
schizophrenia were
significantly lower in the
intervention group than
in the control group

53
Berkowitz,
Eberlein-
Freis, Kuipers
and Leff
(1984)

Berkowitz,
Shavit and
Leff (1990)
Carers and
families
Pre-test/post-
test study with
comparative
design and
randomisation
into two
intervention
groups
United
Kingdom
An educational
program was
conducted
involving 33
participants from
23 different
families of people
with schizophrenia.
Participants were
later randomly
allocated to one of
two social
intervention groups.
Interviews were
conducted prior to
and following the
education program,
and at nine-months
follow-up.

The educational component
comprised four brief
presentations given by
mental health professionals
covering causes, symptoms,
diagnosis, treatment and
course of schizophrenia. The
content of the educational
program was the same as in
an earlier study by Leff et al
(1982), however the
information was presented in
a more personal manner.
Participants received the
information in their homes,
and each family was given
the presentations separately.
After the education
program there were
significant increases in
participants knowledge
about their relatives
diagnosis of
schizophrenia.
After nine months
significantly more
participants stated that
schizophrenia could be
inherited, attitudes to the
ill relative had improved,
and there was increased
optimism for the future
of ill relatives.
There were no
significant differences in
knowledge between
participants in the two
social intervention
groups.

54
Smith and
Birchwood
(1987)
Carers and
families
Pre-test/post-
test study with
comparative
design and
randomisation
into two
intervention
groups

United
Kingdom
Educational
intervention given
to 23 families of
people with
schizophrenia.
Participants were
randomised into
two intervention
groups. Measures
of knowledge and
other effects on the
family were taken
at baseline,
immediately post-
intervention, and at
six-months follow-
up.

Participants were randomly
assigned to one of two
intervention groups. The first
group, the group condition
intervention, received four
educational sessions over a
four-week period. Sessions
included oral and audiovisual
presentations, as well as
general question and answer
discussions. Participants also
received information
booklets and a written
homework exercise. The
second group, the postal
condition intervention,
received only the
information booklet and
homework exercise through
the post each week over the
four-week period.
Information given to both
groups comprised: concepts
and causes of schizophrenia,
symptoms of schizophrenia,
treatments and prognosis,
and hospital and community
resources.

There were significant
increases in knowledge
after the program which
were maintained at six-
months follow-up
The use of group
educational sessions
enhanced the acquisition
of knowledge among
participants
There were reductions in
levels of stress and fear
which were not
maintained after six
months

55
Solomon,
Draine,
Mannion and
Meisel (1996)

Carers and
families
Pre-test/post-
test study with
two
intervention
groups and
randomisation
of controls
(randomised
controlled
trial)
United
States
Study of a program
comparing two
psychoeducational
strategies.
Participants were
225 relatives of
people with severe
mental illness, who
were randomly
allocated to one of
three groups:
individual family
consultation, group
family
psychoeducation, or
a waiting list
(control group).
Interventions were
conducted over
three months, and
participants were
surveyed prior to
and following the
intervention period.

The program involved two
different psychoeducational
interventions: group
psychoeducation and
individualised consultation.
Individual family
consultation involved
between six and fifteen hours
of educational assistance
provided by a specialist
consultant to either the whole
family or one family
member. Group family
psychoeducation comprised
ten two-hour sessions, which
were delivered to
participants in eleven
separate groups, and were
facilitated by trained mental
health specialists and peer
consultants.
There was a
significant
improvement in
participants levels
of self-efficacy
associated with the
two interventions.
Individual
consultation was
more useful than
group
psychoeducation for
those who had
previously attended
family support
groups.

56
Mannion,
Mueser and
Solomon
(1994)
Carers and
families
Pre-test/post-
test study with
no concurrent
controls

United
States
A total of 34
participants took
part in a
psychoeducational
program designed
for spouses of
people with mental
illness.
Questionnaires
were administered
pre-test, post-test
and at one-year
follow-up. 19 of the
participants (68%)
completed
questionnaires prior
to and immediately
following the
program, and 10
(53%) completed
the one-year
follow-up
assessment.

A group psychoeducational
program for spouses was
developed following
collaboration between mental
health professionals and
spouses. It comprised ten
two-hour sessions conducted
over consecutive weeks. A
mental health professional
and a trained family member
facilitated each session.
Sessions involved a 30-
minute oral presentation, a
90-minute discussion of
coping skills, role-play
exercises, written material
and homework tasks.

The program was
effective in improving
participants knowledge
and coping skills, while
reducing levels of
distress and negative
attitudes to the ill
spouse.
Levels of personal
distress were
significantly associated
with attitudes to the ill
spouse.
Improved knowledge
and coping skills were
not associated with
changes in distress and
attitudes.

57
Raskin,
Mghir, Peszke
and York
(1998)
Carers and
families
Pre-test/post-
test study with
no concurrent
controls
United
States
Education program
targeted to
caregivers of
elderly people with
mental illness
living in
community
residences.
Information about
the elderly residents
involved in the
study was collected
prior to and
following the
program.
Participants were
surveyed following
the program in
order to determine
its usefulness.

The education program
comprised two two-hour
presentations conducted over
two weeks. Presenters
included mental health and
allied health professionals.
Information was provided
about causes, symptoms and
treatment of major mental
illnesses, and the provision
of support and care for the
elderly residents. An
information manual was
provided, giving an overview
of symptoms and treatment
of mental illness, focusing on
issues relating to the elderly.
The majority participants
indicated that they found
the program helpful
There was a significant
decrease in the number
of hospital admissions
for the elderly residents
in the twelve months

58
MindMatters
Evaluation
Consortium
(2000)

Wyn, Cahill,
Holdsworth,
Rowling and
Carson (2000)
Adolescents Pre-test/post-
test study with
no concurrent
controls
Australia Pilot mental health
promotion program
undertaken in 24
secondary schools
nationwide. Project
involved
curriculum
resources and
whole-school
approach to mental
health promotion.
Students were
given Knowledge
and Attitude
questionnaire on
three occasions
throughout the
program.

Prior to the program,
professional development
activities introduced the
concepts of Health
Promoting Schools and
MindMatters. Schools
established a core team to
plan and implement the
project. Each school
conducted an audit of current
mental health curriculum and
activities, and utilised
MindMatters resources to
develop appropriate
strategies. Each school
adopted at least one of the
curriculum units: enhancing
resilience, understanding
mental illness, bullying and
harassment, and loss and
grief. Whole-school
strategies were also
undertaken, e.g. youth
forums, and mental health
days. Schools were
encouraged to form
partnerships with community
organizations to enhance the
whole-school approach.

There was a wide uptake
of the curriculum
resources within the
schools, and less activity
in relation to other
aspects of the project
There were some
negative changes in
knowledge about mental
illness following the
program, along with
some positive changes in
social distance attitudes
and help-seeking
intentions

59
Wearing and
Edwards
(1994)
test study with
no concurrent
controls

Australia The School
Education Program
was delivered to
students in Sydney,
then in other states
in Australia in
1994. A total of 162
students were
surveyed prior to
the program, and a
further 25 were
surveyed following
the program in
1994.

The educational component
was presented to school
students by volunteers with
experience of mental illness.
Topics covered in the
presentations included:
definitions of mental illness,
facts and statistics,
community attitudes,
personal experiences of
mental illness, and a
discussion of mental health
resources available to
students. Curriculum
materials were developed
and these included fact
sheets, information packs for
teachers, a video, and
orientation kits for volunteer
presenters. Presenters were
trained in order to enhance
skills in presentation
techniques, as well as
knowledge of mental illness.
The program was revised and
improved between 1992 and
1994, and a program for
students from Non-English
Speaking Backgrounds
(NESB) was developed.

There were some
improvements in
awareness of mental
illness following the
education program
Prior contact with mental
illness was associated
with improved attitudes

60
Rahman,
Mubbashar
and Goldberg
(1998)
test study with
non-
randomisation
of concurrent
controls
Pakistan Mental health
education program
undertaken at two
schools in a rural
area, with two
similar schools
acting as controls.
Participants were
100 students, their
parents, friends and
neighbours, who
were given a
questionnaire prior
to and following the
program.

The educational program
was facilitated in each school
by a mental health team.
Teachers attended training
courses about mental health
disorders, and collaborated
with the mental health team
in developing the educational
program for the school.
Educational activities
included essay writing and
poster competitions and the
production of short plays.
Teachers provided daily
lectures about mental health
issues to the students. Mental
health posters were displayed
in schools. The mental health
teams made weekly visits to
the schools.

Participants who
received the education
program showed
improved awareness of
mental health issues
following the program,
and this change was
greater than that of
control participants
Parents, friends and
neighbours of
participants in the
program also showed
improved awareness of
mental health issues

61
Esters,
Cooker and
Ittenbach
(1998)
test study with
non-
randomisation
of concurrent
controls
United
States
A mental health
education program
was presented to 20
students at a rural
high school. A
second group of 20
students acted as a
control. Participants
completed
questionnaires to
measure attitudes
and knowledge at
baseline,
immediately
following the
intervention, and
again after three
months.

The education program was
presented to the intervention
group over three days. The
program involved an
educational video targeted to
adolescents. Information was
also provided about sources
of help in the community,
including the definitions and
qualifications of different
mental health workers, and
there was discussion of the
stigma associated with
mental illness.
There was a significant
improvement in attitudes
and conceptions of
mental illness in the
intervention group
following the education
program, which was
maintained after three
months
The control group did
not show any significant
change in knowledge
and attitudes

62
Battaglia,
Coverdale and
Bushong
(1990)
Adolescents Post-test only
study with
non-
randomisation
of concurrent
controls
United
States
Mental Illness
Awareness Week
presentations were
given by mental
health professionals
to 1,380 high
school students. A
comparison group
of 280 students did
not attend the
presentations.
Participants
completed
questionnaires
about attitudes
following the
presentations.

Mental health information
sessions were presented to
students at a number of
public schools to coincide
with Mental Health
Awareness Week. The 45-
minute presentations were
given by psychiatric
physicians, and covered
topics including psychiatry,
depression, suicide, and drug
and alcohol issues.
Presenters attended training
sessions in preparation.
Schools were also provided
with manuals detailing
available youth services.

Participants in the
intervention group
reported more positive
attitudes to mental health
professionals and to
help-seeking than those
in the comparison group

63
Bhugra,
Baldwin and
Desai (1997)
Non-English
Speaking
Backgrounds
Pre-test/post-
test study with
no concurrent
controls
United
Kingdom
A pilot study was
conducted targeted
to people from non-
English speaking
backgrounds
involving
educational fact
sheets about
depression.
Participants in the
study were 22
individuals from
the Indian
subcontinent.
Participants were
surveyed about
knowledge of
depression
immediately prior
to and following
presentation of
written information
about depression,
and again
immediately
following a group
discussion.

Educational fact sheets about
depression were produced in
several different languages
as part of the Defeat
Depression campaign
conducted from 1991-1996.
Participants in this study
were presented with the fact
sheets in their preferred
languages, and a follow-up
discussion about depression
was conducted involving the
researchers and study
participants.
Participants knowledge
of depression prior to the
study differed from
those of the overall
population
There were positive
changes in knowledge of
depression immediately
following presentation of
written information.
Improvements in
knowledge were
consolidated by a group
discussion about
depression

64
4. Health communication campaigns

In contrast to the relatively limited amount of literature addressing mental health
literacy programs, there is a vast literature relating to public health information
campaigns. Much theoretical literature is devoted to the topic of effectiveness of
health communication strategies. This section summarises what has been learned from
the research literatures on communication campaigns that may inform mental health
literacy programs.

Generalisations and guidelines from the communication campaign literature are
examined. Critical comments about current communication campaign practice, and
the dominant underlying theoretical model, are then offered. Fundamental differences
between advertising and health communication campaigns are then discussed to place
the previous discussion in context and to provide advice for communication planners.
Drawing primarily on risk theory, and the environmental research literature, a
differing paradigm for conceptualising communication campaigns and risk is
discussed that could be used to complement traditional practices and evaluation
research. In many cases, it is a model that describes current practice where mass
media campaigns are combined with direct interventions at local or community levels.

An overview of selected systematic reviews of communication campaigns that may be
relevant to mental health literacy are examined in Appendix 1 of this report. While it
is beyond the scope of this review to provide an in-depth analysis of all the literature
in this area, it is desirable to provide an overview of some of the key studies and
theoretical literature relating to effective public health information approaches.
Overview of the Communication Campaign Literature
Communication campaigns involving diverse topics and target audiences have been
conducted for decades. Hyman and Sheatsleys (1947) synthesis, Some reasons why
information campaigns fail is an early landmark in the literature. It is important to
investigate how the history of campaign experience and evaluation research may
inform mental health literacy programs.

The seminal synthesis of campaign research by Rogers and Storey (1987) is a useful
departure point. (See also Pettegrew and Logan 1987). Rogers and Storey (1987) note
that there is evidence that communication campaigns can be effective under certain
conditions for specific audiences, but that years of campaign experience suggest many
failures and unrealistic expectations about possible outcomes. The review of the
literature relating to mental health literacy programs clearly demonstrates this point.

Rogers and Storey (1987) observe that in the modern communication campaign,
modest changes in audience behaviour are frequently achievable, and it is important
for the campaign planner to set modest and realistic expectations about what can be
achieved. They argue that a health promotion campaign might be considered
successful or effective if about five percent of the target (or segmented) audience does
adopt measurable changes in health behaviour over the longer-term.

65
In this context, it is important to define a communication campaign. It should be noted
that the word communication is used to highlight the fact that not all campaigns
necessarily involve mass media messages, or mass media messages in isolation, and
that communication campaigns may be small-scale in scope and audience reach.

There is often confusion between the labels campaign, communication campaign or
program, media or mass media campaign, and intervention. No particular definition
adequately covers current practice, and there are many local variations of what is
meant by these labels. Indeed, a variety of definitions exists in the literature but the
following elements of a communication campaign are essential (Rogers and Storey
1987).

Firstly, a campaign is purposive. The specific outcomes can be extremely diverse
ranging from individual level cognitive effects to societal or structural change.
1

Secondly, a communication campaign is aimed at a large audience. Rogers and Storey
(1987) note that large is used to distinguish campaigns from interpersonal
persuasive communications by one individual (or a few people) aiming to seek to
influence only a few others.

Thirdly, communication campaigns have a specified time limit. This is not to state
that all campaigns are short lived. For example, the initial Stanford Heart Disease
Prevention Program ran for three years from 1972 to 1975, however follow-up
investigations were conducted over decades (Pettegrew and Logan 1987).

The fourth point is that a communication campaign comprises a designed set of
organised activities. This is most evident in message design and distribution.
Messages are organised in terms of both form and content, and responsibility is taken
for selecting appropriate communication channels and media. As Rogers and Storey
(1987) point out, even those campaigns whose nature or goal is emancipation or
participation involve organised message production and distribution.

In summary, the term communication campaign implies that:
it is planned to generate specific outcomes;
in a relatively large number of individuals;
within a specified time period; and
uses an organised set of communication activities.

It is this latter element an organised set of communication activities that is the
focus of this section.
Rogers and Storeys Campaign Generalisations
In their extensive literature review, Rogers and Storey (1987) trace the history of
communication campaigns, and offer a set of generalisations based on campaign
research and evaluation. Many of the findings of the present literature review can be
directly related to these generalisations.

An important component of the generalisations comes from analysis of multi-faceted
cardiovascular risk reduction campaigns that have involved extensive tests of the

1
See also Bauman (2000).

66
impact of mass media messages on health behaviours. For example, four American
states, as well as Finland, Australia, Switzerland, South Africa and Germany
(Farquhar 1983) have conducted well-evaluated heart disease prevention campaigns.
The Stanford Heart Disease Prevention program is perhaps the best known. From
1972 to 1975, three communities in California participated in the campaign. Results
showed that in the media only community and the media plus intensive face-to-face
intervention community there were significant reductions in multi-faceted
cardiovascular risk factors, such as weight reduction, cessation of cigarette smoking,
and lowering of cholesterol levels and blood pressure, compared with the no
treatment community.

Stanford Universitys Five Cities Project (Farquhar, Maccoby and Solomon 1984)
built on this previous experience and used larger communities, as well as broader
target audiences. Participants in the project were monitored over eight years, with the
aim of developing an exemplar for other communities. The Minnesota Heart Health
Project (Pavlik et al 1985) showed that campaigns promoting increased physical
activity might be more salient than anti-smoking or other behaviour-cessation
campaigns (Pettegrew and Logan 1985). Pavlik et al (1985) also showed that,
sometimes, relatively inexpensive media, such as pamphlets, brochures and
specialised publications, can be very effective in increasing knowledge about heart
disease prevention.

Pettegrew and Logan (1987) conclude that, in contrast to anti-smoking and alcohol
and other drug campaigns, the cardiovascular risk reduction campaign evaluations
suggest that the mass media can be unilaterally effective in influencing awareness,
attitudes and behavioural changes.

Analyses conducted by Rice and Atkin (1989) and by Pettegrew and Logan (1987)
support the following generalisations by Rogers and Storey (1987). In a very real
sense, these generalisations should be considered as guidelines for communication
campaign planners.

1. Widespread exposure to campaign messages is a necessary ingredient in a
campaigns success.

2. The mass media can play an important role in creating awareness and
knowledge, in stimulating interpersonal communication, and in recruiting
individuals to participate in campaign activities.

3. Interpersonal communication through peer networks is very important in
leading to and maintaining behaviour change.

4. The perceived credibility of a communication source or channel enhances the
effectiveness of a communication campaign.

5. Formative evaluation is as important as summative evaluation following the
conclusion of the campaign.

Formative research involves evaluating aspects of the campaign,
especially message design and audiences understandings, in the

67
planning stages. This work can improve the effectiveness of campaigns
by producing messages that are specific to the desired behavioural
change. The development of the American educational television
series, Sesame Street, is a classic example in the research literature
(Lesser 1974).

6. Campaign appeals that are socially distant from audiences are not effective.

7. Campaigns promoting prevention are less likely to be successful than those
with immediate positive consequences.

8. Audience segmentation strategies can improve campaign effectiveness by
targeting specific messages to particular audiences.

9. Timeliness and accessibility of media and interpersonal messages can
contribute to a campaigns success.
Baumans Precepts and Principles
Similarly, Bauman (2000) offers a set of guidelines, which he characterises as
precepts and principles for campaign planners. These are focused on best practice and
grounded in both campaign experience and evaluations of mass media health
campaigns. His position provides support for Rogers and Storeys (1987) meta-
analysis of the research literature.

Firstly, Bauman distinguishes media campaigns from ad hoc health advocacy that
may involve the mass media. Media campaigns, he says, are purposive and organised
interventions. His guidelines, or precepts and principles, include the following points:

1. Message development should be an integral component of the campaign. As
Rogers and Story (1987) note, formative research is as important, if not more
important, than summative evaluations after a campaign.

2. Process monitoring (process evaluation) is essential. This involves detailed
assessment of each part of the campaigns implementation, providing essential
data on message production and dissemination, and audiences responses.

3. Development of appropriate outcomes is essential. As Bauman (2000) says:
Campaign planners should be clearly focused on the exact outcomes that are
feasible, achievable and measurable.

4. Measurement of carefully defined outcomes is essential (i.e. summative
evaluation).

5. Research designs should include adequate resources and methods to achieve
useful campaign evaluation. As the earlier literature review of mental health
literacy programs demonstrated, valid and useful evaluations are not always
conducted.

6. Bauman argues that, at a minimum, the evaluation budget (formative and
summative) should be more than 15 per cent of the total budget.

68

7. The hierarchy of effects matrix developed by McGuire (1989) is a useful
guide to planning media roles in a campaign.

Briefly, McGuire proposed that only about 50 per cent of an audience
will recall the media message, about half of those will understand the
message, half again will accept it as relevant, half again will shift
attitudes, half of those will adopt the new behaviour, half will trial it,
and half again will maintain the new behaviour. Thus, the role of the
mass media is more likely to be effective in increasing salience of a
campaign message rather than achieving behavioural changes.

As Rogers and Story (1987) note, long-term behavioural change
induced by mass media messages alone is unlikely to be successful.

8. Mass media messages in isolation usually achieve little, therefore other
supportive interventions are essential. These may involve direct, personal
interventions.

Rogers and Storey (1987) make similar observations in their review of
the research literature. Effective mass media campaigns need to be
supported by other direct interventions.
1

9. Over-time monitoring of linked or similar campaigns is important in assessing
the longer-term effectiveness of campaigns. It is important to determine
whether repeated campaigns are achieving net gains, maintaining the status
quo, having no effect, or in fact having a negative effect.

10. Clear frameworks for evaluation should be set by both state and federal
governments to remove or, at least, to reduce any day-to-day politics from
evaluation and policy-making.

11. Dissemination of campaign evaluation results is vital to enable others to learn
from previous campaign successes and failures.
Bauman also briefly discusses the use of so-called social marketing techniques where
a specific campaign attempts to apply a brand to a particular message. The QUIT,
Active Australia and Eatwell Australia campaigns are examples of this strategy.
2

Kotler and Roberto (1989) in particular are strong advocates of the social marketing
approach. It is perhaps important to discuss in a wider context the significant
differences between advertising and health communication campaigns. The following
discussion, designed to inform future mental health literacy campaigns, focuses on
planning realistic expectations rather than relying on the practices and theories about
commercial advertising.

1
A simple illustration of this approach comes from the staff-dining hall at Stanford University, home
of the Stanford Heart Disease Prevention Program, where, many years ago, the menu included data on
fat and cholesterol levels for all food items. This practice is now commonplace for food items in
supermarkets.
2
For a discussion of social marketing, see also Nutbeam and Harris 1998, and Kotler and Roberto
1989.

69
Advertising and Communication Campaigns
Elliott (1987), one of Australias leading communication practitioners, offers a
particularly informative look at the differences between advertising and
communication campaigns. His literature review and analyses of campaigns are
especially relevant because they are based largely on experience. He defines a set of
parameters for considering and planning for a campaigns realistic outcomes.

Elliotts (1987) basic premise is that the objectives and processes that are appropriate
for commercial advertising are usually inappropriate for health promotion. The paper
in effect reconsiders Rothschilds (1979) analysis. The essential differences between
advertising and health campaigns lie in the nature of the product, the processes
involved in promotion and, of course, in the nature of audiences. Elliot argues that
advertising by itself will not result in fundamental changes in behaviour. He quotes
Palyer and Leathar (1981):

Commercial products are regarded by many as trivial and superficial, not as
central and ego-involving to the individual as ill health. They are positive and
attractive and can be relatively easily obtained. By contrast, health publicity is
largely negative: it preaches the avoidance of something negative (which is
enjoyable), often involving short-term unpleasantness, for the sake of benefits
that are long-term, probabilistic and not guaranteed.

Elliott (1987) draws on previous research to demonstrate once again that advertising
does not have massive effects on potential consumers, as many might believe.
However, he notes that small changes in market share for a particular product that are
achieved as a consequence of advertising may result in greatly increased sales and
profits. In this regard, it is useful to recall Rogers and Storeys (1987) assertion that a
health promotion campaign might be considered successful if five percent of the
target audience make longterm changes in overt health behaviour

Commercial advertising techniques are but one element of a communication
campaign using mass media. The following table, comparing communication
campaigns and advertising, has been constructed from Elliotts (1987) literature
review and critical analyses.
Table 3 - Comparison of communication and advertising
campaigns

Typical Communication Campaign Typical Advertising Campaign
Persuasive focus involving response
shaping, reinforcement attitude change;
behavioural change.

Focus on feelings and perceptions toward
product. Not attitude change.

Difficult to specify individual desires and
wants.

Based on the idea of satisfying desires
and wants.
Designed to meet societal or individual
needs in face of risk.

May be designed to create desire and
need.

70
May not be in line with prevailing
attitudes and opinions.

Plays on prevailing attitudes and
opinions.
Usually against the tide of public opinion.

Tries to stay with the tide of public
opinion.

Not usually seen as a personal benefit as
such and may be designed to create a
social benefit.

Usually, if not exclusively, a personal
benefit.

Involves personal cost, sometimes even
discomfort.

Cost is one of choice among competing
brands.

Message is that all people should adopt or
comply.

Products/services that are not accepted
fail.

Often difficult to see short-term
outcomes.
Easy to see, and outcomes can usually be
quantified.

Reward difficult to see. Reward easy to see.

People may express support for socially
desirable behaviour but not adopt the
behaviour.

Experience is the best way to change
attitudes not mass media.

Tries to define communication objectives
as changes in individuals:
Increased salience;
Strengthening or attitude change;
More positive disposition to
behave in a desired direction;
Adoption of behaviour either in
the short or long term;
Awareness of unintended
consequences.

Market objectives often confused with
communication objectives.

Focus on behavioural outcomes with
intermediary objectives such as
reinforcing loyal buyers beliefs, creating
consumer satisfaction, maintaining brand
salience.

May be very sensitive, obtrusive, and
emotional.
May not involve great emotional or
affective attachment.

Many times involves an organisational
bias in the public service/interest.
Educational campaigns favoured even
when evidence shows previous similar
campaigns failed.

Campaigns that fail or result in loss lead
to immediate action.

71
Sometimes, objectives confused with
education or mere dissemination of
information.

Organisation may constrain budget,
processes and structure of the campaign.

All about excitement, sexuality, self-
indulgence, and even power.

Government equated to what ought to be
done, what should be done, etc. It is the
parental mode.

Talks to the child in us.

Information often perceived to be
unreliable because:
Most groups perceive others as the
problem or cause.
Many see themselves compliant
with the attitudes or behaviour,
when they are not
People seek justification for non-
compliance and may give
misleading information in any
evaluation.

Easy to get information about products
and services. Yet, advertising does not
work in the way that most people believe.
Advertising does not have massive
effects on people.
Some people have pre-existing beliefs or
ideas about communication. Unrealistic
expectations about what can be achieved.

Can be targeted to specific audiences or
segments and expectations adjusted.
Often difficult to identify target audience.
Audience could be everyone.
Expectations should be low.

Secondary audiences may be critical in
facilitating change.

Secondary audiences rarely critical in
mass advertising.
Usually a major objective related to a
social concern.

Usually aiming at slight modifications.
Tends to be strategy based on
modifications/change or slow down of
undesirable attitudes/behaviours.

Tends to be strategy based on start or
stop.
Slow processes involved over time. May see instant results.

Televisions commercial values may be
inappropriate to the campaigns message.

Commercial television is commercial
television advertising; the program is
designed to deliver an audience to an
advertiser.

72
Analysis of the Communication Campaign Literature
Much of the literature outlined in the previous discussion, especially by Rogers and
Storey (1987) and Pettegrew and Logan (1987), can be classified as media effects
research. This approach examines the possible effect of communication content on
audiences, or segments of audiences, in terms of changes in knowledge, attitudes or
behaviour. In the case of communication campaigns, the campaign message, which is
disseminated by various media, is typically viewed as the independent or exposure
variable. The effect is the dependent or outcome variable. Thus, researchers have
attempted to link exposure to the campaign information to changes in audience
knowledge, attitudes or behaviours.

The effects tradition has been debated in media theory
1
and is often criticised for its
positivist-like approach and lack of contextualised data (McQuail 1987). Individualist
psychological models underpin the theoretical framework (McGuire 1989). The
campaign message is the stimulus, with the receivers conceptualised as an audience
and, mostly, as a passive audience. This approach does not recognise contemporary
audience analyses or reception theory (Alasuutari 1999; McQuail 1997; Tulloch and
Lupton 1997).

Most early communication campaigns adhere to a narrow conceptualisation of the
communication process. This process may be defined as information transfer and the
mass media and interpersonal networks are seen largely as conduits. The dominant
metaphor is one of communication as the transmission of information (Penman 2000).
In many respects, the use of the term target audience implicitly supports this linear,
knowledge-to-attitude-to-behaviour effects model of communication. Messages are
designed to be shot at a target audience or, as communication scholars have
observed, notions of a bullet theory or hypodermic needle theory underpin the
effects tradition.

In Simkins and Brenners (1984) review of communication campaigns of the 1970s
and 1980s, they note an overemphasis in communication planning on social learning
theory and a preoccupation with the mass media. Most campaign evaluation research,
they note, stems from a linear model of mass communication effects. Such a model is
useful in describing the conditions with which communication-for-change programs
must contend in the planning and design stage for persuasion campaigns (Simpkins
and Brenner 1984). The model, however, does not explain why outcomes occur as a
result of the communication programs.

Atkin (1981) also argued that research into the use of mass media to improve public
knowledge about health was one-dimensional because it focused on what was the
most effective media channel radio, newspapers or television to create persuasive
communications. Few studies examined how various publics acquired health
knowledge or how they were motivated to attend to public health campaigns.

Pettegrew and Logan (1987) note that the degree to which health care values held by
health care providers, public and government coincided or conflicted was largely
ignored in the campaign research literature of the 1970s and 1980s. Graham (1981),
for example, explores the false conception about value in scientific or health

1
See, for example, Gitlin 1978.

73
knowledge. Conventional wisdom assumed that scientific knowledge was determined
within the scientific paradigm, which is free and immune from the impact of social or
cultural values. As a consequence, communication planners of that time might be
forgiven for seeing the mass media as a delivery system. The goal was to exploit
mass media campaigns to influence public education with only minimal loss of
scientific data. Or, to follow the communication as transmission metaphor, the goal
was to reduce unnecessary noise in the transmission of pure scientific and health
knowledge. The research and planning focused on the source, message, channel and
receiver, conceptualised as an engineering problem of process and feedback.
However, as Graham (1981) observed, scientific theories and health knowledge are
constantly influenced by public, social and cultural values.

From a policy perspective, the communication process continues to be approached
from what may be considered a flawed perspective. The transmission of information
metaphor is so dominant in popular thinking that it may direct government and its
agencies to invest unwisely in campaigns whose expectations are highly unrealistic.

Contemporary communication campaigns are far more likely to recognise the capacity
of audiences to make meaning out of campaign messages, to misinterpret messages,
or even to resist messages. Baumans (2000) concern with realistic expectations about
outcomes, formative evaluation, and long-term summative evaluations is an example
of this. The related issue of understanding audiences, and of segmenting audiences in
campaign planning, is also interwoven with understanding peoples grounded
knowledge and values.
Discourses
Several scholars have advocated a health communication research program grounded
in cultural theory, which could complement existing approaches (Tulloch 1992;
Tulloch and Lupton 1997). One way to advance such an approach is to focus research
attention on discourses. By extension, campaign planners might also incorporate
contemporary theoretical notions of risk.

The term discourse refers to mean a system of knowledge and practice representing
social and material phenomena that shape individuals perceptions of reality and of
the self (Tulloch and Lupton 1997). Media discourses, medical discourses, health
communication discourses and, most importantly, lay discourses about mental health,
are constantly in conflict over the production of meaning. Research into
contextualised knowledge is often lacking in evaluation studies about the complex
relationships between campaign messages and audiences understandings.

A culturalist approach offers a different way of conceptualising the communication
in communication campaigns, which moves away from reliance on the knowledge
attitudebehaviour model that underpins most effects studies and communication
campaigns of the past. To examine only the end effects of campaign messages ignores
the contest over the production of meaning, the unintended consequences of campaign
messages, subtextual discourses, and the likely unpredictable responses of various
audiences. Contemporary cultural theory acknowledges that the production and
reception of meanings are highly contextual, contingent in time and space, as well as
intertextual (Tulloch and Lupton 1997).

74
Discourse and frame analyses should explore meanings in communication campaign
messages, the mass media, and the daily lives of audiences. It is important to
investigate the factors that various audiences bring to their experience and reception
of communication campaign messages and to the mass media. Methods such as
participant observation, unobtrusive techniques, ethnography and ethnomethodology
may be appropriate for investigating the multiple meanings that audiences produce
from the campaigns and mass media about health messages as they go about their
daily lives (Tulloch and Lupton 1997).

Some elements of the research literature explore the use of mass media by health
professionals to influence audiences understandings and knowledge of health issues
(Atkin and Wallack 1990). The research focuses particularly on television
entertainment programs. Tulloch and Morans (1986) examination of the television
series A Country Practice is a useful example of this.

In the next section, the experiences drawn from risk communication campaigns are
discussed. The origins of such campaigns are primarily in environmental
communication. This discussion is especially important for campaign planners in
terms of focusing on audiences and the values they bring to any communicative
process, including a communication campaign. The model that emerges from this
research may be seen as a way of recognising changing practices in health
communication campaign planning.
The Concept of Risk
Most health communication campaigns involve risk, i.e. risks to people and societal
risks. The concept of risk has been at the focus of contemporary thinking in recent
years because of the salience and threat of environmental issues, which have received
extensive public and media attention.

Giddens (1996) observes that most traditional cultures did not have a concept of risk
and argues that it is a concept associated with modern industrialised civilisation,
embodying ideas about controlling or conquering the future.

Lupton (1999), Tulloch and Lupton (1997), and Lash, Szerszynski and Wynne (1996)
focus on risk as an individual concept. People are forced to negotiate their lives
around risks, and to rely increasingly on their own judgments about risks. Experts can
assess the likelihood and magnitude of a given risk, however the public understanding
of a given risk takes on meaning through our cultural practices. (See also Adams
1995).

One important cultural site for the production of meanings about risk is media
content, including communication campaigns. The meaning of a particular health risk
to various groups in society, for example, develops through the continuing and often
changing representations of that risk in media content, and in scientific and medical
discourses, as well as through other social and cultural practices. It is against this
background of changing technical, media and public discourses that communication
campaigns are planned.

Wynne (1996) argues that, just as expert opinion is central to ideas about risk, so too
is lay criticism and comment. He observes that, while risks may be debated within

75
scientific or public accountability discourses, they are dealt with by most people as
individuals in very specific situations, at the level of the local, the private, the
mundane, the everyday, and intimate experiences. Wynne argues that it is essential to
examine how perceptions of risks are constructed by local, or as he terms it situated,
knowledge, as well as by expert knowledge.

Tulloch and Lupton (1997) demonstrate, for example, that there are profound
differences across class, gender, race, ethnicity, age and other variables in the ways
people understand, interpret and respond to health risks. Individualism might suggest
a degree of choice in negotiating risk, but it is recognised that, within the power
structures of our society, some people have more authority over the ways risks are
identified, defined as public, and managed, than do other people.
1
Anecdotally, it has
been noted that a teenage boy will ask for the cigarette packet with the warning label
Smoking is dangerous to pregnant women because it doesnt apply to him.

This risk perspective offers invaluable insights for communication campaign planners.
This section of communication literature has one point of origin in the environmental
sciences, and is particularly important to review because of its parallels to more
general communication campaigns.
Risk Communication Campaigns
Risk communication campaigns of the 1980s offered the promise of resolving public
conflict and diminishing fear about new large-scale technologies, such as nuclear
power, as well as promoting safety campaigns concerned with science, technology
and health (Blood et al 2000; Covello et al. 1986; Rohrmann 1992). The concept of
communication being in the public interest was viewed as essential in fulfilling the
publics need for information and education, or for promoting behavioural change and
protective action, in the face of an anticipated disaster or hazard.

Brown and Campbell (1991) note that many western societies recognised the need for
public information about science and technological risks. They link heightened
interest in risk communication to the emergence of environmental impact legislation
and the requirement to inform the public.

The early risk communication campaign model involved expertsattempting to
persuade the public of the validity of their scientific and technical risk assessments of
a particular hazard. It is perhaps unsurprising that many such campaigns met with
limited success, as the reviews outlined above would predict. Rohrmann (1992)
observes that actual risk communication practices differed widely in terms of
substantive issues addressed, audiences, information, methods of communication, and
communication contexts.

1
Tulloch and Lupton (1997) cite a vivid example from their research on HIV/AIDS at the time of the
famous Grim Reaper campaign with its final message Always use condoms, always. A young pre-
teenage Aboriginal girl told them she had unprotected sex because condoms are chicken (cowardly).
The authors note that this young womans life involved daily personal risks. She was underprivileged,
involved in petty crime, was continually in and out of remand homes, stole cars, and had been chased
by the police. They conclude that using a condom might indeed seem chicken. Her group was one
among the many in contemporary society that takes pleasure in risk activities.

76
A fundamental change in campaign planning occurred in the late 1980s with the
recognition that public perceptions of various risks differed widely. This change is
viewed historically as a turning point for risk communication research (Hadden 1989;
Dake 1992). As Hadden (1989) observes, old risk communication models, such as
those involving scientific experts attempting to persuade lay people of the validity of
their risk assessments and decisions, are impeded by lay risk perceptions, by lay
peoples difficulties in understanding mathematical probabilities, and by technical and
scientific difficulty.

Leiss (1998) argues that the changed research direction is a shift in emphasis from
risk to communication in the concept of risk communication. In other words, it
involves re-framing the issue of risk communication as a problem in communication
theory and practice, rather than in the concept of risk.

Research conducted by Slovic (1987) and Fischhoff et al (1978) is illustrative of the
trend towards identifying generalisablerisk perception factors. Risks perceived as
familiar, controlled, voluntary, beneficial, and fair are more likely to be acceptable to
most people than risks perceived in opposite ways (Slovic et al 1981). For example,
the perceived health risks of chemical pollution from a local industrial factory are
different from the perceived risks from exceeding the speed limit on a country road:
the first is involuntary and unfamiliar, while the latter may be considered voluntary
and familiar.

Risk perception research adds to the body of knowledge in this area by accounting for
seemingly irrational responses by various publics to identified and potential hazards.
It should be noted that the same risk might in fact produce very different perceptions
in differing groups of people, depending upon the context in which the risk is
understood and interpreted. These varied perceptions may produce differing policy or
strategic decisions about risk management and responses by experts (Bradbury
1989). Rowan (1996) puts forward the following argument about generalised
perception factors:

[The factors] are expressions of various types of power: informational,
decisional and distributional. People who feel deprived of facts, unable to
control their own lives, and forced to bear the costs but not the benefits are
likely to be outraged by news of some new risk. To be effective risk
communication must involve power sharing. Therefore, risk communication
may not reduce conflict and smooth risk management. Empowerment can be
destabilising in the short term, but it leads to more broadly based policy
decisions, which can hold up over the long term.

As a consequence, contemporary risk communication campaigns attempt to be more
individually reflexive and, as Hadden (1989) and Fisher (1991) argue, the key to this
approach lies in establishing dialogue or conversations with the public.
1
The notion of
one-way, top-down, expert-to-public campaigns is replaced with a more interactive
process designed to empower various publics. Campaigns recognise that
understanding the complexities of health issues, including technical knowledge, are
not necessarily beyond ordinary people. They also highlight the potential importance

1
See also Leiss 1998 transmission model.

77
of the interplay between scientific forms of knowledge and those that may be
considered are more cultural. In other words, lay knowledge about health issues
cannot be ignored in communication campaigns.

Hadden (1989) notes that campaigns that emphasise dialogue among parties and
active participation in assessing and managing risk, are impeded by the lack of, or
difficulty in establishing, participatory institutions. Similarly, in a health context,
Needleman (1987) notes that the goal of empowering those at risk to make an
informed choice is laudable, however the risk communication intervention needs to be
more than merely the dissemination of information:

The intervention must, somewhere along the line, stimulate individual and/or
collective behavioural changes that reduce health risks. Otherwise, the risk
communication becomes a kind of ritualistic activity, an end in itself in which
the formal aspects of conveying risk information take precedence over their
actual health impact. [Emphasis added].

The emergence of a participatory or dialogue model, which attempts to explore the
disparity between expert information and a diverse public knowledge, has challenged
both the scientific approach to the problem of risk communication, and indeed the
later perception research.
1

Brown and Campbell (1991) have placed risk communication models within a two by
two matrix that categorises the underlying approach in terms of low and high power
devolvement, and low and high community interaction. Older models of risk
communication are low in terms of both power sharing and community interaction, in
contrast to newer dialogue models that are high in power sharing and high in
community interaction (see Table 4).

1
The need for this new approach is succinctly made in an editorial in the American J ournal of Public
Health. Marmot (1996) comments on the public response in Britain to Creutzfeldt-J akob diseased beef,
where little reliable data were available, compared with replicable studies linking moderate alcohol
consumption to breast cancer:

Alcohol and beef are consumed by approximately the same proportion of the British
population. Beef is as much part of the culture and economy as alcohol. Is it dread in the face
of an unknown and currently unknowable magnitude of risk that has led to the greater reaction
to beef? . Scientific evidence relating exposure to harm may be necessary but is far from
sufficient for actions affecting the public health.

It is not appropriate to dismiss this disjunction simply as politics. It is indeed politics, but the
lesson extends further. In the latest turn of events, and not for the first time, the public was
ahead of the politicians and distrustful of them. The real lesson is that we need a better
understanding of the management and communication of risk.

78
Table 4 - Risk Communication Conversation Models

COMMUNITY INTERACTION
Low High
Information Consultation
Leaflets Public Meetings
Displays Planning
Low
CSAs Inquiries

Canvassing Conversation
Surveys Searching
Focus groups Planning Cells
POWER
SHARING
High
Interviews

CSAs =Community or Public Service announcements, usually on television.
Table from: Brown, J . and Campbell, E. (1991).

The key message from Brown and Campbells (1991) table to communication
planners is to take full account of the day-to-day experiences, perceptions and cultural
values of various audiences in the formative stages of any campaign. Formative
research should go beyond simple quantitative measures to include more reflexive,
cultural understandings of campaign messages and audiences. Of equal importance is
the need to understand what various audiences bring to the reception process in their
use of mass media, and their use of mass media in terms of understanding health
issues.

British researcher J enny Kitzinger, who has completed many studies on health issues,
says (1994):

We are none of us self-contained, isolated, static entities; we are part of
complex and overlapping, social, familial and collegiate networks. Our
personal behaviour is not cut off from public discourses and our actions do not
happen in a cultural vacuum. We make sense of things through talking with
and observing other people, through conversations at home or at work; and we
act (or fail to act) on that knowledge in a social context. When researchers
want to explore peoples understandings, or to influence them, it makes sense
to employ methods, which actively encourage the examination of these social
processes in action.

The notion of an active dialogue model may appear idealistic or impractical, however
it should be contrasted with the failures of the dominant top-down campaign
strategies, which comprised the older risk communication approach. An active
dialogue model examining expert and lay knowledge should not be viewed as
ignoring technical health knowledge. The approach explicitly acknowledges the

79
legitimacy of all sources of knowledge central to risk dialogue, including technical
knowledge (Handmer 1995). It acknowledges the importance of investigating the
interplay between various discourses, including scientific, medical, health, media, and
lay discourses, in planning any communication campaign.
Summary
There is evidence that communication campaigns can be effective under certain
conditions for particular audiences. It should, however, be recognised that experiences
drawn from diverse communication campaigns suggest many failures and unrealistic
expectations about possible outcomes. In terms of modern communication campaigns,
fairly small changes in audience behaviour are frequently achievable, and an
important key for the campaign planner is to set modest and realistic expectations
about what can be achieved.

It should be noted that not all communication campaigns necessarily involve mass
media messages, or mass media messages in isolation, and that communication
campaigns may be small in terms of scale and audience reach. The role of mass media
campaigns in particular is more likely to be in creating awareness and knowledge of a
campaign message rather than achieving behavioural changes. Bauman (2000) argues
that mass media messages alone usually achieve little, and therefore other supportive
interventions are necessary.

In order for a communication campaign to be successful, a number of components are
considered essential. Message development is an integral component of the campaign,
and there should be widespread exposure to campaign messages. Campaign appeals
that are socially distant from audiences are generally ineffective, and messages
promoting prevention are less likely to be successful than those with immediate
positive consequences. Measurement of carefully defined outcomes is important, and
research designs should include adequate resources and methods to achieve useful
campaign evaluation. In addition, monitoring of linked or similar campaigns over
time is important in assessing the longer-term effectiveness of campaigns.
Dissemination of campaign evaluation results is particularly important to enable
others to learn from previous campaign successes and failures.

Much of the literature included in this section can be classified as media effects
research, which tends to focus on the possible effect of communication content on
audiences in terms of changes in knowledge, attitudes or behaviour. The effects
tradition has been debated in media theory, and evaluations of early communication
campaigns have been criticised for an overemphasis on social learning theory, which
stems from a linear model of mass communication effects and does not explain why
outcomes occur as a result of the communication programs. In contrast, contemporary
communication campaigns need to recognise that audiences have the ability to make
meaning out of campaign messages, and even to misinterpret resist messages.
Baumans (2000) recommendations for campaign planners place an emphasis on
determining realistic outcomes, and conducting both formative evaluation and long-
term summative evaluations.
A newer approach to communication campaigns offers a culturalist perspective.
This model moves away from reliance on the knowledgeattitudebehaviour
paradigm that underpins most of the earlier effects studies and communication

80
campaigns. It acknowledges the importance of investigating the factors that various
audiences bring to their understanding and reception of communication campaign
messages. The model that has emerged from the experience of risk communication
campaigns in particular acknowledges the importance of investigating the interplay
between various discourses, including scientific, medical, health, media, and lay
discourses, in planning any communication campaign.

81
5. Conclusions
Research question

Two main categories of mental health literacy programs were identified in this
review: whole of community programs, and those targeting specific sub-groups within
the population. With respect to programs designed to reach the general public, there is
evidence that mass media campaigns can achieve positive outcomes in terms of
mental health literacy, particularly when combined with community activities.
Previous reviews of the literature have also found that mass media programs can alter
knowledge of and attitudes to issues of mental health and illness, however it is
recognised that the impact of media programs is limited (see Appendix 1).

It is important to note that most of the evidence of effectiveness of mass media
approaches comes from campaigns conducted overseas, with relatively few
evaluations in the Australian context. Earlier reviews of the literature have pointed out
that, where the majority of previous research has been conducted in other countries,
this may not be a sound basis from which to draw conclusions for different settings
(Tilford, Delaney et al. 1995). In view of this, recommendations should be considered
as a starting point from which to develop and modify campaigns. It is clearly
important that programs conducted in Australia be evaluated to determine the
characteristics of successful programs in the local setting.

Support for the effectiveness of mass media campaigns can be found in the general
health communication literature. Reviews of the evidence relating to communication
campaigns have concluded that widespread exposure to campaign messages is
necessary for the success of a campaign, and that the mass media in particular play a
key role in creating awareness and knowledge, in stimulating interpersonal
communication, and in encouraging individuals to participate in campaign activities.
Bauman (2000) and Rogers and Storey (1987) found that media messages alone
usually achieve little, and that other supportive direct interventions are necessary.

Research focusing on mental health literacy also indicates that campaigns are
particularly effective when they involve more than one form of media, and include
community-based components and/or direct interventions (Fonnebo and Sogaard
1995; Sogaard and Fonnebo 1995; Paykel et al. 1997; 1998). Previous reviews of the
literature in this area have similarly concluded that mass media campaigns
supplemented by smaller-scale community activities represent the most effective
approach to improving mental health literacy among the general public.

Mass media campaigns outlined in the current review differed in their ability to reach
the population. Those involving television broadcasts supplemented by other media
activities tended to have greater audience penetration. The Norwegian Mental Health
Campaign, which comprised a television program and other media and community
activities, reportedly reached 94% of the study population (Fonnebo and Sogaard
1995; Sogaard and Fonnebo 1995). In contrast, the educational television series You

82
in Mind received an audience equivalent to 13% of the adult population in the UK
(Barker et al 1993).

Although there is evidence that mass media programs can be effective in modifying
knowledge and attitudes, it is important to note that the impact of such campaigns is
limited. Much of the attitudinal change identified in studies of mass media campaigns
was relatively small in magnitude, and in the larger-scale interventions it was unclear
whether positive findings could be attributed solely to the impact of the campaign, or
whether other factors may have contributed. This aspect of mass media campaigns is
recognised in the health communication literature, particularly in the area of
behaviour change. It has been found that communications campaigns can be effective
under particular conditions for specific audiences, and that while relatively modest
changes in audience behaviour are often achievable, it is important to set modest and
realistic expectations about what can be achieved.

In addition, it is recognised that mass media campaigns are expensive, particularly
those involving television broadcasts, and it may be that other approaches are more
cost-effective. Mental health literacy programs that target the general public but do
not involve mass media approaches appear to be less common, but show some
evidence of effectiveness in terms of attitude change. Importantly, studies of such
programs have found that direct contact with individuals with mental illness is
associated with the development of more positive attitudes. Previous reviews of the
literature have also indicated that smaller scale approaches such as educational texts
and seminars may be more cost-effective for certain audiences.

It is recognized that a number of sub-groups within the population may be appropriate
for targeted mental health literacy programs. Earlier reviews of the literature have
recommended that the development phase of a program should involve consideration
of the audience and the overall goals, as these will help to determine the message and
the medium chosen for the campaign, and ensure that resources are used most
effectively.

With respect to programs targeting specific audiences, there is evidence from the
literature that school-based programs can improve mental health literacy among
adolescents. School-based programs included in this review differed in terms of
content and mode of delivery. For example, the School Education Program (SEP)
involved trained presenters visiting schools to provide information to students, while
the MindMatters program provided resources and training to teachers to enable the
program to be incorporated into the overall school curriculum (Evans Research 1999;
MindMatters Evaluation Consortium 2000; Wyn et al. 2000).

It should be noted that important methodological issues emerged in a number of
studies focusing on school-based mental health literacy programs, particularly those
conducted in Australia, which prevent firm conclusions being drawn. It is
disappointing that the evaluations of both MindMatters and the School Education
Program (SEP), which were conducted in Australian schools, were unable to provide
adequate data about impact on mental health literacy (Evans Research 1999;
MindMatters Evaluation Consortium 2000; Wyn et al. 2000). It is important that
future evaluations of school-based mental health literacy programs in Australia focus

83
on assessing the impact of programs on knowledge, attitudes and behaviour, in order
to provide a sound evidence base.

When considering the mode of delivery of school-based programs, it is important to
note that, in their review of the effectiveness of school-based health promotion,
Fletcher, Stewart-Brown and Barlow (1997) concluded that traditional educational
health programs are effective in improving knowledge of health issues but do not
produce lasting behavioural changes. They suggest that more innovative programs can
bring about significant changes in health behaviour, and propose that a promising
strategy for school-based health promotion campaigns is a more holistic approach
with a core mental health or emotional well-being program delivered throughout the
school years.

Some of the strongest evidence of effectiveness of mental health literacy programs
comes from studies of educational interventions for carers and family members of
people with mental illness. In particular, programs for family members of individuals
with schizophrenia have been evaluated in a range of studies and found positive
results in terms of improvements in knowledge and attitudes. In addition, a number of
studies found that programs resulted in improvements for mental health consumers,
although it was generally unclear whether the educational component of the
interventions was responsible for this outcome, or whether social aspects of the
intervention may have contributed. It may therefore be concluded that, while many of
the educational programs resulted in improved knowledge of mental illness, it was not
found that changes in knowledge had any significant impact on other variables.

When considering the evidence of effectiveness of health communication programs, it
is clearly important to bear in mind the theoretical basis for communication strategies.
It is apparent from the literature, however, that theoretical issues are not adequately
addressed in studies of mental health literacy programs. Research in this area tends to
focus on the possible effects of communication content on audiences in terms of
changes in knowledge, attitudes or behaviour. This is particularly true of studies
relating to the mass media. However, such an approach has been criticised for an
overemphasis on a linear model of mass communication effects, or the knowledge
attitudebehaviour paradigm.

It is important for campaign planners to recognise the factors that various audiences
bring to their understanding and reception of communication campaign messages.
Contemporary theory acknowledges that there are complex relationships between
campaign messages and audiences understandings. Research into mental health
literacy campaigns should take into account how various audiences acquire health
knowledge and what factors motivate audiences to attend to public health messages.
In order to achieve this, Bauman (2000) in particular emphasises the importance of
formative evaluation and process evaluation, to provide essential information about
message production and dissemination, and the responses of various audiences.
Importantly, Bauman recommends that campaign planners be clearly focused on
outcomes that are feasible, achievable and measurable.

84
Supplementary questions:
a) To what extent have such strategies improved levels of knowledge and awareness,
achieved attitudinal change and/or behavioural change and/or achieved positive
changes to broader community attitudes which may have had a flow-on effect to
mental health consumers?

There is evidence that mass media campaigns have achieved changes in
knowledge of and attitudes to mental illness, however such changes have been
quite small in magnitude. It is also unclear from a number of the studies whether
the campaigns themselves have resulted in the changes measured in the studies, or
whether other factors may have contributed. Community education programs
utilising other modes of delivery, such as education courses, similarly found
positive changes in attitudes and knowledge, however the number of studies
looking at this approach is relatively limited. Evaluation of school-based programs
for adolescents generally found that there was an impact on awareness and
attitudes, however it should be noted that the two school-based programs
conducted in Australia were unable to provide adequate assessments of
effectiveness.

Many studies did not attempt to measure behavioural change, and those that did
generally relied on self-report measures, which were unable to be validated. It is
possible that in a number of studies, reported changes in behaviour or intentions
were over-stated. As noted earlier, reviews of health communication campaign
literature have found that mass media campaigns alone are unlikely to achieve
widespread or long-term behaviour change. Media campaigns are important in
generating awareness and improving knowledge about health issue, however other
supportive activities are required to produce significant behavioural change.
Rogers and Storey (1987) point out, however, that, given the limitations of
communication campaigns, a program may be considered effective even if
behaviour change is limited to a very small segment of the target audience.

Reducing the level of stigma and discrimination experienced by people with
mental illness was recognised to be an important aim of many of the programs
included in this review, however the majority of studies did not actually attempt to
measure flow-on effects for mental health consumers. Evaluations of programs
targeted to carers and families of people with mental illness were the exception to
this. Overall, these studies found that rates of hospitalisation and relapse rates for
people with mental illness may be reduced by educational interventions targeted
to carers and family members. However, no direct association was found between
improvements in participants mental health literacy and beneficial effects for
mental health consumers.

b) What are the determinants of successful public health information strategies, for
example, strategy development, selling the message, communication tools (eg
print, radio, television and/or film), post-strategy follow-up and cost
effectiveness?

In terms of mental health literacy programs, it is clear that a number of elements
are associated with successful campaigns. In particular, determining the goals of

85
the campaign and the characteristics of the target audience are essential to ensure
that the message and mode of delivery of the campaign are appropriate. When
developing campaign messages, it has been found that campaigns that
communicate the benefits of a particular attitude or behaviour change to the
general public are more effective than attempting to convey concepts alone. This
is supported by the findings of Rogers and Storey (1987) in their review of the
communication campaign literature. They found that campaigns that promote
prevention are less likely to be successful than those with immediate positive
consequences, and that messages that are socially distant from the audience
member are not effective. A number of studies of mental health literacy programs
have also found that campaigns which are able to achieve direct contact between
the audience and mental health consumers are associated with improved attitudes.

Literature relating to general health communication strategies also recognises the
importance of campaign strategy development. In this context, formative
evaluation is viewed as a necessary part of a successful campaign. This involves
evaluating aspects of the campaign, especially message design and audiences
understandings, in the planning stages. This work can improve the effectiveness
of programs by producing messages that are specific to the goals of the campaign.

Determining the most appropriate communication tools depends largely on the
target audience and the goals of the campaign. In the current review, mass media
campaigns which have reached the largest proportion of the general public were
those which utilised television broadcasts in association with other media
promotional strategies. An example of this was the Norwegian Mental Health
Campaign, which achieved 94% awareness in the population (Fonnebo and
Sogaard 1995; Sogaard and Fonnebo 1995). The success of this campaign was
attributed to the wide variety of media and community activities undertaken, as
well as the support provided by government and high profile individuals and
organisations. Studies of other forms of health communication campaigns have
also found that positive changes in attitudes and awareness tend to be associated
with programs that utilise both mass media and community strategies, rather than
media or community activities alone.

Programs that are designed to reach particular target groups may be delivered
more effectively through approaches other than mass media. School-based
programs are effective at reaching school-aged adolescents, however it should be
noted that not all individuals in this age group will be reached through such
programs. Mental health literacy programs for carers and families have been
shown to be effective when delivered in a group educational setting. Such an
approach has been shown to be more effective than the provision of written
information alone.

It is important to note that none of the studies included in this review adequately
investigated cost-effectiveness of mental health literacy programs. While there is
some evidence that mass media approaches can achieve changes in awareness and
attitudes in the wider population, it is recognised that such strategies are costly.
Studies of cost-effectiveness are appropriate in this area, particularly as there is
evidence that community activities can enhance mass media approaches, and may
prove to be a more cost-effective approach for certain target groups.

86

c) Which determinants of successful strategies and campaigns apply to all
populations and which to particular target audiences?

Previous reviews of the literature have concluded that mass media campaigns may
be most effective at reaching the general public, while programs targeted to
specific sub-groups or which are designed to produce behaviour change may be
delivered more effectively through smaller group or community-based
approaches. It has also been found that mass media strategies may be more
effective at achieving long-term change in awareness and attitudes if they are
complemented by community activities.

The current review tends to support these findings. Campaigns involving large-
scale mass media approaches were often able to reach a significant proportion of
the general population. However, it was also found that changes in attitudes and
knowledge achieved through mass media approaches are limited, and therefore
smaller-scale strategies may be more appropriate and cost-effective for particular
target groups. In particular, community-driven activities and public education
courses combined with mass media campaigns may result in greater changes in
knowledge and attitudes than media approaches alone.

As stated earlier, programs that have focused on particular audiences have
generally been delivered in a school-based setting, or targeted to carers and
families of people with mental illness. While programs focusing on other target
groups may have been initiated, few evaluations have emerged from which to
make judgements about effectiveness. Overall, there is evidence that school-based
programs are effective in improving attitudes and knowledge among adolescents,
however the evidence of effectiveness of Australian programs is less strong.
Programs targeted to caregivers and relatives of people with mental illness have
also been shown to be effective, and, importantly, may result in beneficial effects
for people with mental illness.

It should be noted, however, that all studies of programs for carers and families
have been conducted in the US and the UK, and therefore such programs may not
be directly transferable to the Australian context. Despite this, it is clear that this
group is an important audience for targeted mental health literacy programs. In
addition, there is a need for further evaluation of strategies which will effectively
focus on other target groups, such as mental health consumers, people from non-
English speaking backgrounds, and individuals at high-risk of developing mental
illness.

d) Which successful public health information strategy models are transferable in
terms of content and/or process across topic areas and/or demographic groups in
Australia?

Most of the programs studied were conducted in countries other than Australia. It
is therefore difficult to determine to what extent successful programs may achieve
the same effects in the Australian context. The issue of transferability of programs
was recognised in a large-scale review of effectiveness of mental health
promotion programs conducted for the Health Education Authority in the UK

87
(Tilford, Delaney et al. 1995). The review found that most evidence came from
countries other than the UK, and therefore conclusions about applicability to the
UK context were tentative only. A similar recommendation may be made for the
current review, as only three of the studies were conducted in Australia. In
addition, significant methodological issues emerged in a number of these studies,
particularly those investigating school-based programs, and the strongest evidence
tends to come from evaluations of overseas studies.

In terms of transferability of content and process across different settings and
target groups, several issues need to be addressed. Program content may not be
transferable between different geographical regions, or between different
demographic groups. It has been noted that campaigns must be carefully tailored
to particular audiences, and therefore a program designed for adolescents that is
delivered in a school setting is not likely to be appropriate for older age groups, or
for target groups such as mental health consumers. It is important to recognise that
audiences are diverse, and, in particular, cultural and language differences must be
taken into account when designing or transferring program content. In terms of
geographical regions, information about resources, health services, and treatment
options may differ greatly between different countries and states, and even
between metropolitan and rural areas.

Selecting the most appropriate mode of delivery may also be quite specific to
particular regions and target groups. As has been noted, mass media campaigns
are generally suited to whole of community campaigns, while other strategies may
be more effective for targeting sub-groups of the population. Although a number
of overseas studies have found that mass media campaigns are more effective
when supplemented by community-based activities and direct approaches, there
have not been any evaluations of such techniques in the Australian setting.

e) In which areas may further research be commissioned on public health
information approaches to mental health literacy?

A number of important areas for future research have emerged from this literature
review. Firstly, there is a lack of strong evidence of effectiveness of mental health
literacy campaigns in the Australian context. Only three of the twenty-one
programs reviewed were conducted in Australia, and the findings of a number of
these studies were inconclusive. There is a clear need for evaluation of mental
health literacy programs in Australia, both in terms of campaigns targeted to the
general population, and those aimed at particular sub-groups.

While a number of target populations for mental health literacy campaigns have
been identified, relatively few programs in this area have been evaluated. For
example, no studies were identified which investigated programs designed
specifically for mental health consumers or individuals at risk of developing
mental illness. In addition, only one program targeted to people from non-English
speaking backgrounds was found for inclusion in the review (Bhugra, Baldwin
and Desai, 1997). As this was a small-scale pilot study conducted in the UK, it is
unclear whether the results would be applicable either to the wider population or
to the Australian context. There is therefore a need for evaluation of such

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programs, in order to determine the characteristics of mental health literacy
campaigns that are effective for particular target groups.

The issue of cost-effectiveness has not been addressed in previous studies of
mental health literacy campaigns. This is clearly a key area for further research,
particularly as many programs tend to involve high cost strategies such as mass
media campaigns. It is important to determine to what extent particular outcomes
may be achieved using smaller-scale and less expensive methods, especially as
more direct, community-based approaches have been found to be an important
component of successful campaigns.

As discussed earlier, the health communication literature emphasises the
importance of formative evaluation and process evaluation of communication
campaigns. Much of the previous research has focused on evaluation of outcomes,
and has tended to neglect evaluation of the development and implementation
phases of communication and information programs. It is also recognised that
monitoring of linked or similar campaigns over time is important in assessing the
longer-term effectiveness of campaigns. It is clearly important that future research
involves appropriate resources and methods to achieve useful evaluation of
strategies to improve mental health literacy.
Methodological Issues
Important methodological limitations were identified in many of the studies in this
review. Issues about study design, in particular, arose in much of the literature. These
limitations must be taken into account when interpreting any findings, as they have an
important impact on the strength of any conclusions that may be drawn from the
literature.

The studies selected for inclusion in this review may be classified generally as
program evaluation research. In view of this, it is important to consider the nature and
methodological approaches of program evaluation, in order to inform future research
in the field of mental health literacy.
Program evaluation
Program evaluation involves the assessment of a program to determine its merit,
worth or value (Hawthorne, 2000; Scriven, 1991). A program may be defined as a
planned set of activities directed towards bringing about specified changes in an
identified and identifiable audience (Smith 1988). As such, the expected outcomes of
a program may be identified and measured, along with unforeseen or unexpected
program effects.

Evaluation research uses the scientific method to assess the worth of a program, in
order to make judgments about a programs intended and unintended outcomes
(Hawthorne 2000). The term scientific method refers to the use of research methods
that enable any findings or outcomes to be attributed to a particular cause, in this case
to the activities of a program (Hawthorne 2000). Such research methods involve:
a) a strong research design that minimises bias, distortion or confounding and
that maximises the generalisability of findings;
b) the use of sensitive, valid and reliable measurements;

89
c) the generation of outcome data that are standardised in some way so they are
stable, and they can be identified and described; and
d) conclusions drawn from logical reasoning, based on deductive and inductive
thinking, such that they are stated with a degree of precision which can be
universally understood.
Forms of evaluation
Evaluation may be classified into three broad categories: formative evaluation,
process evaluation and summative evaluation (Scriven 1991; Hawthorne 2000).
Formative evaluation is generally conducted during the development stages of a
program, in order to provide feedback to program planners during the design phase.
Process evaluation involves monitoring the implementation and operation of a
program, to determine whether program activities are conducted as intended.
Evaluation conducted after the completion of a program is generally classified as
summative evaluation.

Summative evaluation involves assessment of the effects of a program, and can be
categorised as either impact evaluation or outcome evaluation (Hawthorne 2000).
Impact evaluation aims to measure the immediate or short-term effects of a particular
program, such as changes in knowledge, attitudes or behavioural intentions. These
measures may be considered surrogate criteria for the actual long-term aims of a
program, e.g. changes in a populations health status or behavioural change. In
contrast, outcome evaluation assesses the long-term effects of a program, such as
actual behavioural changes, rather than merely the immediate impacts.
Evaluation study design
Evaluations of health or social programs, such as those designed to improve mental
health literacy, may involve a number of different approaches. Selection of a study
design will depend on a number of important factors. It is necessary to consider
general issues about the aims, resources and context of the evaluation, as well as
specific issues relating to the validity of the research (Hawthorne 2000; Grembowski
2001).

The selection of a study design will depend largely on the purpose of the evaluation
(Hawthorne 2000). Where an evaluation aims to determine causality, it is generally
appropriate to choose an experimental research design. In contrast, for a study that
aims to understand an aspect of human behaviour, an observational design may be
more suitable. In addition, it is important to consider the actual context and setting of
the evaluation. While a particular study design may be considered most appropriate to
achieve certain aims, it may not be feasible to implement such a design in all
situations.
Types of study design
Study designs are generally classified as one of three basic types (Colton 1974;
Kumar 1996; Scriven 1991; Hawthorne 2000; Grembowski 2001):
experimental;
quasi-experimental; or
pre-experimental / observational.

90
Experimental designs are those in which the investigator has control over participants,
treatment and observations. They involve two or more groups, at least one of which
consists of participants who receive a particular treatment, while a second group
forms a control or comparison group. An important feature of experimental designs is
the randomisation of participants into either the treatment or control group.

The most commonly referred to form of experimental design is the pre-test/post-test
control group design, or randomised controlled trial. This study design involves
randomisation of participants into treatment and control groups, with observations or
measurements conducted prior to and following the treatment or intervention phase.
Another common form of experimental design is the post-test only control group
design, which involves randomisation into treatment and control groups, with
observations conducted following the intervention only.

Quasi-experiments have some features that are similar to experimental designs. They
involve treatment and control groups, however there is no randomisation of
participants into these groups. Good quasi-experimental designs aim to match the
control group as closely as possible to the treatment group, in order to minimise
differences between the two groups.

One of the most common examples of quasi-experimental design is the pre-test/post-
test non-equivalent control group design. This study design involves control and
treatment groups without randomisation of participants. Selection or matching criteria
are often applied to minimise differences between the groups. Observations are
conducted prior to and following the treatment phase. Another form of quasi-
experiment is the separate samples pre-test/post-test design. This design is
commonly used when studying interventions in large populations. It involves the use
of two separate samples of participants, with observations conducted in one sample
prior to the treatment, and post-treatment observations conducted in the second
sample.

In pre-experimental or observational designs, the investigator has little or no control
over participants, treatments and observations in the study. Such designs are limited in
their ability to establish causality, i.e. whether observed changes are actually caused
by a particular intervention. One example of this design is the post-test only with
non-equivalent groups design. This involves the use of treatment and control groups
that have not been matched, with observations conducted in both groups following the
treatment only.
Research validity
When selecting a study design for a program evaluation, issues of internal and
external validity must be taken into account. The concept of internal validity refers to
a studys ability to make accurate causal inferences about the impacts of a particular
program (Grembowski 2001). In other words, the study should be able to determine
whether any observed changes caused by the program itself, rather than by other
factors. Certain study designs tend to have fewer threats to internal validity than
others (Hawthorne 2000; Grembowski 2001). In particular, experimental designs have
higher internal validity than quasi-experimental designs, which in turn have higher
internal validity than pre-experimental, or non-experimental, designs.

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The issue of external validity arises when considering whether the results of a
particular study can be generalised to other settings, populations or time periods. In
order to consider external validity, it is first necessary to determine that the study has
internal validity. When determining external validity, issues to consider include
whether the study setting is comparable to other potential settings, and whether the
sample population included in the study can be generalised to the wider population.
Selection of study design
Studies included in this literature review tended to be summative evaluations, i.e.
studies that aimed to measure the effects of a particular program. When selecting a
study design for a summative evaluation, it is important to note that some study
designs will facilitate more accurate and generalisable findings than others. Studies
involving a before-and-after, or pre-test/post-test, design are generally considered to
be the most appropriate for summative evaluations (Kumar 1996; Hawthorne 2000).

Summative evaluations tend also to be conducted from an experimental evaluation
perspective (Hawthorne 2000). The aim of such an investigation is to measure the
effects of a program in a rigorous manner, to determine whether any observed
changes are in fact caused by the activities of the program, rather than by other
factors. In order to achieve this purpose, studies involving an experimental design
with comparison groups and randomisation are preferred (Grembowski 2001). One of
the most common examples of this form of experimental design is the pre-test/post-
test control group design, or randomised controlled trial (RCT).

It is important to note, however, that an experimental study design is not always
feasible when evaluating a health program (Hawthorne 2000; Grembowski 2001). In
view of this, evaluators often use study designs that are defined as either quasi-
experimental or pre-experimental / observational. Where true experimental designs
are not used, it is important that threats to internal validity are reduced. One example
of a study design commonly used in summative evaluation research is the pre-
test/post-test non-equivalent control group design. This is a form of quasi-experiment
involving treatment and control or comparison groups without random allocation of
participants. This is considered to be a strong design, particularly where there are
selection or matching criteria, such as age and gender, to minimise differences
between the groups of participants (Hawthorne 2000; Grembowski 2001).
Program logic
Evaluations of public communication campaigns, such as mass media campaigns,
raise specific methodological issues. In particular, it is often difficult to separate the
effects of such campaigns from those due to external influences (Owen 1993). The
use of experimental study designs is often not feasible when evaluating this type of
program, as mass communication approaches are generally conducted at a population-
wide level, and it may not be possible to control for external factors in this setting.

These difficulties may be overcome to a certain extent by the use of program logic
approaches as part of the evaluative process. Program logic methodology involves the
clarification of the logical causal path underlying a programs activities (Hawthorne
2000). The aim of this process is to elucidate intended program outcomes, as well as
the causal mechanisms underpinning these outcomes. It involves clarification of the

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programs theory of action, which is particularly important in the evaluation of
complex programs.

Importantly, program logic modelling allows for evaluation of outcomes at different
stages of the program. For example, intermediate outcomes that form part of the chain
of events leading to a programs ultimate outcomes can be clarified and measured
(Owen 1993). This process provides information about the characteristics of
successful and unsuccessful programs at each stage, rather than simply relying on
measurement of ultimate outcomes.

As stated earlier, the causal mechanisms underlying a particular programs activities
and any observed effects may be difficult to ascertain. It is important to recognise that
summative evaluation is not the only approach to investigating the merit or worth of a
particular program, and may not always be appropriate. In many circumstances
consideration should be given to conducting either a formative or process evaluation
of a program, for which the development of a program logic model is particularly
appropriate.
Summary
Evaluations of mental health literacy programs may involve a number of different
approaches. Studies included in this literature review tended to be summative
evaluations, i.e. research designed to measure the effects of a particular program. The
aim of such an investigation is to measure the impact of a program in a rigorous
manner, to determine whether any observed changes are in fact caused by the
activities of the program, rather than by other factors. When choosing the most
appropriate study design for a summative evaluation, it is important to recognise that
some study designs will facilitate more accurate and generalisable findings than
others.

In general, a before-and-after, or pre-test/post-test, design is considered to be the most
appropriate for a summative evaluation. In addition, an experimental study design
involving randomisation of participants into treatment and control groups is preferred,
as such designs tend to have high internal validity. It is important to note, however,
that a true experimental study is not always feasible when evaluating a health
program, and therefore evaluators often use either quasi-experimental or pre-
experimental / observational study designs. Where such study designs are used for a
program evaluation, it is important that threats to the internal validity of the study are
identified and reduced.

Evaluations of public communication campaigns raise specific methodological issues.
Mass communication approaches are generally conducted at a population-wide level,
and often it is not possible to control for external influences. The use of experimental
study designs may therefore not be possible in these settings. When evaluating such a
program, consideration should be given to developing a program logic model.
Program logic methodology involves clarification of the programs theory of action
and the logical causal pathway underpinning a programs activities. This process can
assist in elucidating the characteristics of successful and unsuccessful programs at
each stage, rather than measuring only the ultimate outcomes. In many circumstances
it may also be appropriate to conduct a formative or process evaluation of a program,
for which the development of a program logic model is often a key component.

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Appendix 1 Previous reviews of the literature
Reviews of Mental Health Literacy Programs
The literature relating specifically to improving mental health literacy is not large, and
consists largely of studies of individual programs, papers providing background
information, and policy framework documents. In addition, a number of large-scale
reviews of the literature have been conducted in recent years. Most of these involved
reviews of mental health promotion and mental illness prevention programs in
general, and therefore many of the programs reviewed do not specifically relate to
improving mental health literacy. An overview of this previous research is provided in
this section, as a number of the findings are of relevance to the development of
effective mental health literacy programs.
Day (1987)
Improving community education strategies for mental health
promotion.
In an early review of the literature relating to mental health education programs, Day
(1987) provided a number of recommendations for the development of effective
mental health promotion campaigns. While these recommendations specifically
referred to the development of Canadian programs, it is worth considering their
relevance to the Australian context. In the review, Day examined a number of aspects
of mental health education programs, in particular: the message, the audience, the
medium, and the goals and objectives of the program. The review included 39
references, comprising both studies and books, most of which were published prior to
1980 and are therefore not included in the current literature review.

With respect to the theme and content of mental health education campaigns, Day
found that messages should be interesting and informative, but also simple enough for
the information to be conveyed easily to the target audience. The content of the
message and theme of the campaign may vary according to the aims of the program.
Increasing awareness generally requires the presentation of simple and direct
information, while modifying attitudes may require more persuasive techniques. A
program that aims to modify behaviour requires more complex content with a sound
theoretical basis, such as social psychology theory. The review also stated that
authoritarian pronouncements should be avoided, as these tend to create anxiety in
the audience when applied to the subject of mental illness.

Day found that most mental health education campaigns were directed towards the
general public, and that such an approach often did not succeed as it did not take into
account the varied characteristics of the audience. Day recommended that programs
designed mainly to increase awareness and interest in mental health issues should be
targeted to the general population, however programs designed to modify certain
behaviours should be targeted to specific groups. Three groups were identified to
whom mental health education should be directed: those vulnerable to emotional
disorder, those in positions of power in the community, and those with caregiving
roles.

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When considering the appropriate medium for conveying mental health messages,
Day noted that the mass media were the most important method for the presentation
of such information. However, he pointed out that mass media formats are costly, and
may oversimplify issues. He stated that small-group discussion formats might be more
effective at achieving long-term changes. Day recommended moving towards a
participant model of mental health education, rather than more passive approaches.
He stated that the most effective campaigns would involve media presentations to
improve perception and awareness of the issues, which were then followed by small
group presentations and discussions in order to promote attitude and behaviour
change. Overall, Day recommended that the development of effective campaigns
involved taking into account all the elements of the program already outlined, and that
future programs should be evaluated to increase the body of literature regarding
effectiveness.
Tilford, Delaney et al (1995)
Effectiveness of mental health promotion interventions: a literature
review.
More recently, a large-scale review of mental health promotion interventions was
undertaken for the Health Education Authority in the UK (Tilford, Delaney et al.
1995). This review included 72 studies, the majority of which (71%) were from the
United States. The aim of the review was to identify interventions that had been
shown to be effective in preventing mental disorders and promoting positive
wellbeing. While a number of studies related specifically to improving mental health
literacy, the majority did not. Those that related to mental health literacy were
generally mass media interventions directed to the whole community. It was found
that there was evidence that mass media campaigns can modify knowledge and
attitudes to mental illness, however it was acknowledged that the impact of such
campaigns is limited. The authors noted that the impact of media campaigns might be
enhanced by complementary community activities, which corresponds with the
findings of the review conducted by Day (1987).

Mental health promotion studies targeted to specific groups generally did not involve
programs to improve mental health literacy, but were instead focused more
specifically on interventions designed to prevent mental illness and promote overall
wellbeing, such as courses on self-esteem and coping skills. Despite the relatively
small number of mental health literacy programs included in the review, the authors
made the recommendation that children as a group should have access to health
education curriculum that incorporates mental health components.
Hodgson, Abbasi and Clarkson (1996)
Effective Mental Health Promotion: a Literature Review.
Another major review of the literature relating to mental health promotion
interventions was undertaken by Hodgson, Abbasi and Clarkson (1996). They defined
mental health promotion as the enhancement of the capacity of individuals, families,
groups or communities to strengthen or support positive emotional, cognitive and
related experiences. The review focused on evidence from studies that were either
randomised controlled trials or quasi-experimental designs. As with the review by
Tilford et al (1995), most of the studies identified for the review were conducted in

95
the US, however the focus for this review was slightly narrower, and very few of the
programs reviewed related specifically to mental health literacy.

The authors concluded that there was clear evidence that mental health promotion
programs can be effective, and that many successful programs utilise a targeted rather
than universal approach in order to modify particular risk or protective factors. They
stated that the identification of individuals who are likely to receive benefit from a
particular program is an important issue, to ensure that resources are used wisely. The
authors also recommended the implementation of multi-national studies to determine
the generalisability of study findings between different countries and settings.
Krupinski and Burrows (1989)
Mental health promotion policy strategies for Australia.
An Australian review of mental health promotion and prevention programs by
Krupinski and Burrows (1989) differed from those discussed previously in that it
aimed to assess the state of mental health promotion and prevention activities in
Australia at the time, rather than provide a detailed review of the literature. A total of
50 programs relating to mental health were identified through the computerised data
base Health Education and Promotion Information System (HEAPS), and the majority
of these related to relaxation and stress management. Information about a further 268
programs was obtained through a survey of relevant organisations. Of these, 21%
were educational programs, however it is unclear whether any of these were designed
to improve aspects of mental health literacy. The authors noted that very few of the
programs had undergone systemic evaluation.

The recommendations of the review were that mental health promotion programs
should be targeted to the population as a whole, and prevention activities should be
targeted to particular at-risk or mental illness groups. The authors proposed that
programs directed to the general population should focus primarily on increasing
community knowledge and awareness of mental illness and issues related to mental
health, as well as altering negative community attitudes to mental illness. They stated
that the best method of conveying information to the general population was through
the mass media, and proposed that broadcast media, periodicals, and local papers may
be the most appropriate vehicles for mental health education. The authors also
recommended educational books and brochures as an inexpensive method of
disseminating information, although they acknowledged that such information would
probably be most effective at reaching those who were already interested in mental
health issues.

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Reviews of Communication Campaigns
Given the relatively small amount of literature focusing on mental health literacy
programs, it is useful to extend the literature review to other areas of health
communication. The following section provides an overview of selected major
reviews of communication campaigns on related health issues such as, alcohol,
tobacco and other drug use, drink driving, sexual matters, HIV/AIDS, road safety, and
youth issues.
Shanahan, Elliott and Dahlgren (2000).
Review of public information programs addressing youth risk-
taking.
This report, commissioned by NYARS, involves a critical literature review focused
on evaluations of national and international mass media communication campaigns
designed to improve the health of young people. It includes a study of attitudes of
selected managers of Australian mass media campaigns directed at youth and
addressing youth risk taking.

In our view, this is a significant paper that deserves special attention by Australian
communication campaign planners. Although focused on youth risk-taking, the
conclusions and suggestions have wider implications. Overall, the authors concluded
that barriers to the effective development of a public communication campaign
included the following:

Unrealistic expectations;
The absence of a clear set of objectives;
Poorly defined target groups or audiences; and
The failure to develop successful messages for its intended audience.
Additionally, campaign managers raised the pragmatic constraints of limited
budget and time, a scarcity of personnel and resources, as well as the need to
satisfy political objectives.

Unrealistic expectations and unachievable goals emerged as a prime barrier to the
effectiveness of public communication campaigns; a point made in earlier reviews of
the campaign literature.

In general, campaigns aimed to achieve one or more of the following:

Agenda setting: increasing the salience of a particular risk-taking behaviour by
attracting community attention;
Improving levels of knowledge and awareness;
Achieving changes in behavioural intent;
Achieving changes in social norms;
Sustaining safer behaviours by young people; and
Achieving attitudinal changes among the broader community, which have a
flow-on effect to young peoples attitudes and behaviour.

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Achieving behavioural change was generally acknowledged as an extremely difficult
goal. Evidence from the literature indicated that advertising on its own rarely led to
wide behavioural change, particularly in the area of health.

Changes in behaviour were more likely to eventuate over a long period of time, and
only if the mass media communication was supported by other activities (such as
community-based interventions, sponsorship, public relations). Changes in awareness
or salience of a particular health issue can be achieved in the relative short term, and
awareness raising or signposting the need to change, can be a legitimate campaign
goal.

The report identified elements of a successful campaign:

The implementation of a thorough planning stage;
The use of research: to help define the target groups, to understand the issue
from the target groups point of view, to test alternative messages, and to
evaluate the campaign;
The establishment of realistic and achievable objectives;
The linking of media campaigns to other supporting activities (eg community
and/or school-based activities);
The utilisation of more than one form of media; and
The provision of sufficient time and resources to enable the campaign to
achieve its objectives

It is suggested that health communication campaigns need to adopt broader and more
aggressive strategies. Campaigns must target children younger than has been the
norm. It is suggested planners: micro target strategies to the needs and interests of
different ages and environments; provide consistent messages from a variety of
sources and over a long period of time; and emphasise giving children control and
ownership of their own destinies.

The report also highlighted the need to adopt a step by step process in planning
procedures. This relates directly to setting realistic aims and a workable strategy, the
use of an appropriate theoretical model, and the implementation of a range of research
procedures.

The report noted that campaign managers interviewed for the study made specific
mention of the need at the planning stage to include on the management team relevant
expertise for the various campaign components. This strategy development, they said,
might include expertise in research, public relations, advertising, and media.
Processes involve the development of a communications brief, the gathering of
existing research and data on the campaign issues, and the conduct of developmental
or exploratory research. (As in formative research, mentioned above).

Accurately identifying the target audiences for a proposed mass media campaign was
highlighted. Extreme care needs to be taken in determining the target groups and in
understanding their attitudes. Planners need to understand the world view of the so-
called youth target groups. Planners should examine closely the likely age, gender and
demographic differences among a youth target group, as well as differing attitudes

98
and behaviours. Youth is not a homogeneous group and careful differentiation is
essential.

The report also notes the importance of developing meaningful messages. Campaign
managers interviewed were adamant that the key to reaching the target groups
effectively for a mass-media-led public campaign was knowledge of the target
audiences, as well as the use of images and language with which they could readily
identify.

A range of issues were examined including the benefits of using research to pre-test
alternative messages (formative research), and of involving youth in communication
development, as well as discussion of the use of negative and positive approaches,
and fear or threat appeals, in communications to youth.

Evidence suggested that most effective media campaigns use a range of media,
choosing different media according to their different strengths to create a synergistic
communication. The report noted the importance of choosing appropriate media,
effective use of placement, and related audience experiences in the use of television,
radio and print. Other media vehicles, such as comics and videos, were examined ,
which may be useful in reaching alienated youth.

The report also noted the role and importance of complementary and coordinated
activities, such as public relations, sponsorship, and school and community based
activities. Generally, there was strong support among those campaign managers
interviewed for complementary activities to any mass media campaign. The use of
community based activities, promotional events, and the like, often give teeth to the
campaign and provide some tangible way of reaching the target audiences through a
social or cultural channel, the managers said.

There was considerable evidence, the report said, that mass media campaigns will
only have a substantial impact if they are integrated with other intervention strategies.
The report noted that adequate evaluation techniques are infrequently used.

The researchers identified the following factors that limit the potential of the mass
media:

The amount of activity contrary to health campaign objectives that appear in
the media;
The shortcomings of the media (eg failure to reach the target audiences,
insufficient time, etc);
Insufficient time allowed for the campaigns;
Lack of funding;
Poor media placement and timing;
The sometimes over-simplification of complex behaviours;
Cultural factors working against the aims of health campaigns; and
The inherent difficulties of communicating to youth.

The report concluded:

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Expectations of what mass media campaigns can and cannot do need to be
carefully considered.

There is a tendency to believe that mass media can reach everyone and,
on exposure, change behaviour. This belief follows the theory of
mass media influence known as the bullet theory, hypodermic
needle theory or direct effects model. The assumption is that the
audience is passive and the mass media is powerful and capable of
influence and persuasion, and of affecting attitudes and behaviours.
(See Section 5).

Evidence suggests that mass media campaigns, aimed at improving public
health, can:

Increase awareness of a problem, or at-risk behaviour;
Raise the level of information about a topic or issue;
Help form beliefs, especially where beliefs are not held firmly;
Make a health issue more salient and thereby sensitise the audience to
other forms of communication (eg personal communication,
school/community-based activities, public relations, brochures etc);
Simulate interpersonal influences via conversations with family or
friends, teachers etc;
Generate forms of self-initiated information seeking; and
Reinforce existing attitudes, beliefs and behaviours.

Determining appropriate gaols of a mass media campaign emerges as one of
the key considerations.

Goals should be set at the outset, and they need to be realistic and
attainable. Successful campaigns have achievable goals and have not
attempted to create too much change. Many campaigns have raised
awareness of an issue or signposted the need for behavioural change,
which, in turn, can be supported by other means. Random Breath
Testing media campaigns and complementary legislation is an
example.

Evidence also suggests that it is better to seek a slight change in
attitudes or behaviours and, where possible, build upon existing
attitudes and opinions.

The more successful campaigns have used a variety of media and
implemented support activities as an adjunct to the main messages conveyed
through the mass media.

In developing any campaign directed at reducing or minimising youth risk-
taking, it is important that at the outset a clear understanding is gained (and
agreement reached) on who are the target audiences.

Accompanying this requirement is the need to have an understanding
of the target audiences attitudes and motivations. That is, how do the

100
target groups construe risk taking? What is and, importantly, what is
not risk-taking from their perspectives? What are the situational and
environmental factors impacting on their attitudes, behaviours and
motivations? (A review of risk communication campaigns is provided
in Section 5.)

Understanding the audience is critical.

The way an audience currently behaves and what it believes will
determine what it will eventually do with the campaign messages.
Audiences, especially youth audiences, are active recipients of
campaign messages, interpreting and accepting or rejecting what is
being communicated to them.

The diversity of sub-cultures within the youth population makes it difficult to
develop a message that will gain uniform understanding or acceptance. Target
segmentation and the implementation of different messages for different sub-
groups should always be considered. There is no single target group or
audience. The focus should be on audiences.

The diversity of youth attitudes and behaviours indicates that there are
some who, for various reasons, will not respond to a communication
campaign at all. Other approaches, such as comics, community-based
activities and direct personal interventions, need to be considered for
these subgroups.

101
Fletcher, Stewart-Brown and Barlow (1997).
Systematic review of the effectiveness of school-based health
promotion
This report on several reviews critically evaluated the effectiveness of school-based
health promotion campaigns concerning alcohol abuse, substance abuse, tobacco
control, sexual health, accident prevention and mental health issues. The goal was to
identify common attributes of successful and meaningful interventions. [Method of
data collection is included with the review paper].

Most of the reviews and primary studies were carried out in America. The review
identified two main approaches to health promotion activities in schools
traditional and innovative. Traditional approaches are pedagogic, focusing on
provision of information to students. Teaching method involve lectures, question and
answer sessions, and provision of reading materials. Innovative approaches based on
active methods include programs such as:

Decision support programs, which teach children how to make rational
decisions about particular behaviours.

Self esteem programs focusing on the development of individual feelings of
self worth and value.

Resistance skills training, which teach students to identify pressures and
assertively resist influences towards risk-taking health behaviours.

Life skills training, which helps students to develop generally, and teaches
broad social skills such as communication skills, human relations skills and
ways of solving interpersonal conflict.

Norm setting programs, which help establish conservative norms within the
group and focus on correcting erroneous assumptions that everyone is doing
it.

Counselling and assistance programs, which use peer help methods.

Pledge programs, which encourage students to state publicly that they will
behave in a certain way as a form of social reinforcement.

Value clarification programs, which examine tensions between individuals
stated values and the likely consequences of risk-taking health behaviour, and
seeking to demonstrate that the two are incompatible.

Overall, the paper concluded that traditional pedagogic health programs are
effective in increasing childrens knowledge of health topics but do not produce
lasting behavioural changes. The report suggested that more innovative programs
could bring about significant changes in health behaviour but that it is difficult to
quantify the impact of the interventions from the results presented in the reviews
identified.

102

The report suggested that a promising strategy for school-based health promotion
campaigns is likely to be a generic or holistic approach with a core mental health or
emotional well-being program delivered throughout the school years. This should be
combined with knowledge-based modules on smoking, drugs, sexual behaviour,
accidents and other aspects of looking after yourself, such as diet and exercise.
Further trials of this approach need to evaluate their impact in combination with
community-based interventions. This model has many features in common with
WHOs Health Promoting Schools initiative.

Alcohol abuse campaigns:
Effects of alcohol prevention campaigns in schools, in terms of behavioural outcomes,
are modest at best. The traditional pedagogic programs produced changes in
knowledge similar to those produced by the more innovative programs, but they were
much less effective in terms of behavioural change.

Substance abuse campaigns:
The results are consistent with the findings of reviews in other areas. When
knowledge is the outcome of interest, many programs are effective in bringing about
changes. Change in knowledge, however, does not necessarily translate into changes
in behaviour, and this calls into question the assumptions of traditional, rational
methods of behaviour change.

Students are less receptive to adult-led campaigns than to peer-led campaigns, and
even more resistant to authority figures such as the police advising them to change
their attitudes and behaviours. Interactive programs (with perhaps some skills
training) led by people not perceived by students to be in authoritarian roles or
establishment positions appear to work better. Motivation (as measured by volunteer
status) is a useful marker in successful behavioural change.

Tobacco control campaigns:
While the traditional methods focused on information provision produce effective
results in terms of influencing knowledge acquisition, they were much less effective
than the innovative methods in changing behaviours. Traditional approaches produced
greater knowledge change in the short-term but smaller behavioural changes than the
newer approaches in general. The report suggests adopting social reinforcement
programs (McAlester et al 1980). The use of programs based on social or
developmental approaches are also recommended as effective alternatives.

Sexual health:
Very few evaluations have been conducted of sexual health campaigns in schools, and
most existing studies were conducted in North America. Results show that many
factors, in addition to school-based campaigns, influence childrens and young adults
behaviours with the result that campaigns may only have only a small impact on
behaviours.

103
Accident prevention reviews:
The report points to conflicting findings, perhaps attributed, in part, to the large
number of methodologically flawed studies. For example, one review showed road
education to be effective while another suggested such interventions were ineffective.
Educational interventions aimed at increasing bicycle helmet use were found to be
generally effective. There was some fairly convincing evidence (from one review)
that a number of other educational interventions aimed at young children are
effective, suggesting that young children can be taught using school-based campaigns
to wear bicycle helmets, ride bicycles more safely, wear seat-belts, learn to swim and
to take care to avoid burns.

The report says, however, that there are difficulties in predicting responses of
adolescents to the content of different campaigns programs highlighted by the
reviews. For example, one review showed that interventions designed to improve the
safety of young drivers could actually produce the opposite effect; that is, higher
accident or mortality rates in the intervention groups. Two reviews included studies
on school-based interventions combined with community interventions and concluded
that this could be a more promising approach. (Also see Elliott, 1989).
White and Pitts (1998).
Educating young people about drugs: A systematic review.
The report assessed the effectiveness of campaigns directed at the prevention (or
reduction of use) of illicit substances by young people, and campaigns directed at
reducing harm caused by continuing use. [Methods used are included with the paper].

The majority of studies identified were evaluations of campaigns in schools about
alcohol, tobacco and marijuana use. These studies were methodologically stronger
than interventions targeting other drugs and implemented outside schools.

The report concluded that the impact of evaluated interventions was small with
dissipation of program effects over time. Interventions targeting hard to reach groups
have not been evaluated adequately, and there is still insufficient evidence to assess
the effectiveness of the range of approaches to drugs education. The report concluded
that there is a need to target interventions to reflect the specific needs and experiences
of recipients.
Coleman et al (1996)
The effectiveness of interventions to prevent accidental injury to
young persons aged 15-24 years: Review of the evidence.
This review assessed the effectiveness of campaigns aimed at preventing accidents, or
injury minimisation, among adolescents and young adults aged 15 to 24 years. It is an
important report because it compares direct interventions with educational
campaigns. Interventions were classified into three broad categories: engineering,
educational and enforcement. Outcomes assessed in the review included: decrease in
rates of accidents; reduction in the severity of injury; and increased knowledge and
attitudinal change.

Not surprisingly, the report concluded that the most effective interventions appear to
be legislative or regulatory controls, which in road, sports and workplace settings are

104
associated with fewer accidental injuries in adolescent populations, although reported
changes in numbers of accidents occurring may be because of variations in exposure.

Interventions evaluated in well-designed trials for which there was good evidence to
support their recommendation were: raising the minimum legal drinking age between
18-21 years, motorcycle helmets, environmental engineering changes to sports
environment and prophylactic injury prevention programs.

Interventions in which there was fair evidence to support their recommendation were:
bicycle helmets, area wide urban traffic safety, sped control hubs, curfew, airbags and
seat belts, subsidised public transport, warning notices combined with low cost
compliance measures to encourage use of protective devices, smoke detectors.

Interventions in which there was good or fair evidence to reject their recommendation
were: formal enhanced pre-car licence driver training and education, driver
improvement programs for problem drivers, and periodic motor vehicle safety checks
and random roadside inspections.

Thus, the report supports Shanahan et als (2000) suggestion that communication
campaigns may increase salience of a health issue, but that other interventions are
necessary to achieve behavioural outcomes.
Sowden and Arblaster (2001a).
Community interventions for preventing smoking in young people.
The report determined the effectiveness of community interventions in preventing the
uptake of smoking in young people. The authors examined the effectiveness of
community interventions compared to no intervention in influencing the smoking
behaviour of young people. Secondly, the report examined the effectiveness of
community interventions compared to other single component interventions (eg
school-based programs) in influencing smoking behaviour of young people. [The
report includes the method of selecting studies for review].

Of nine studies comparing community interventions with no interventions, two
studies (part of cardiovascular disease prevention campaigns) reported lower smoking
prevalence. Of three studies comparing community interventions with school-based
campaigns, only one found differences in reported smoking prevalence. One study
reported a lower rate of increase in prevalence in a community receiving a multi-
component intervention compared to a community exposed to a mass media campaign
alone. One study reported a significant difference in smoking prevalence between a
group receiving a media, school and homework intervention compared with a group
receiving the mass media component only.

105
The report concluded that there is some limited support for the effectiveness of
community interventions in helping prevent the uptake of smoking in young people.
The report recommended that:

Communication planners build upon results of existing programs that have
been shown to be effective rather than repeating methods that have achieved
limited success;

Programs need to be flexible and recognise difference between communities
so that the various components of a given campaign can be modified to
achieve acceptability;

Developmental work with representative samples of those individuals to be
targeted should be carried out so that appropriate messages and activities can
be implemented;

Campaign messages and activities should be guided by theoretical constructs
about how behaviours are acquired and maintained (for example, social
learning theory); and

Community activities must reach the intended audience if they are to stand any
chance of success influencing the behaviour of that audience.
Sowden and Arblaster (2001b)
Mass media interventions for preventing smoking in young people.
The report assessed the effectiveness of mass media communication campaigns in
preventing the uptake of smoking in young people. [The method of selecting studies is
included with the report].

Two studies concluded that the mass media were effective in influencing the smoking
behaviour of young people. Both of the effective campaigns had a solid theoretical
base, used formative research in designing the campaign messages, and message
broadcast was of reasonable intensity over extensive periods of time. In one study,
provocative messages were developed and used to cause affective personal reactions.
It was hypothesised that this would lead to discussion and interpersonal
communication, which would lead to reductions in smoking.

In the other study reporting reductions in smoking behaviour, a program based on the
social influences or social learning theory approach was developed.

The report concluded that there is some evidence the mass media can be effective in
preventing the uptake of smoking in young people, but overall the evidence is not
consistently strong.

The report recommended the following for communication campaign planners:

Build upon elements of existing campaigns that have been shown to be
effective rather than repeating methods that have been successful;

106
Developmental work with representative samples of the target audience should
be carried out so that media messages appropriate to the group can be created;

Campaign messages should be guided by theoretical concepts about how
behaviours are acquired and maintained;

Media messages must reach the target audiences (via media channels preferred
by the target audiences at the most appropriate times);

Broadcasting of campaigns should be of sufficient intensity, frequency and
duration to have a reasonable chance of being effective;

Preference for either radio or television is likely to depend on age.
Serra et al (2000).
Interventions for preventing tobacco smoking in public places.
The report evaluated the effectiveness of campaigns to reduce tobacco consumption in
public places. [The method of selecting studies for review is included with the report].

The most effective campaigns used comprehensive, multi-component approaches to
implement policies banning smoking within institutions. These were where
institutions developed, resourced and supported comprehensive programs to achieve
compliance with a policy decision to ban smoking. Two hospitals in Baltimore, USA,
showed high rates of success from a strategy that included education, dissemination of
information, training for managers, and support in quitting for individual smokers.
Less comprehensive strategies, such as posted warnings and educational material, had
a moderate effect. Five studies showed that prompting individual smokers had an
immediate effect, but such strategies are unlikely to be acceptable as a public health
intervention.

The report concluded that carefully planned and resourced, multi-component
campaigns effectively reduced smoking within public places. Less intensive strategies
have a partial effect, but there is little effect from regulations or signage not supported
by other means. Requests to smoking individuals can reduce short-term smoking but
are not an acceptable public health strategy for reducing exposure to smoke.

All the studies used relatively weak experimental designs. Most studies were
undertaken in the USA and there is a need to identify ways in which these strategies
could be adopted and used in countries with different attitudes to tobacco use. The
report recommended that future studies should consider the use of more rigorous
evaluation methods.

107
Cochrane Tobacco Addiction Group (1999)
Preventing the uptake of smoking in young people.
The report noted that the uptake of smoking is a complex process and is rarely a
single, distinct or discrete event. The influence of family members and peers is
strongly associated with the decision to start smoking. The report found the following:

School based campaigns:
School-based programs have achieved limited success, although social reinforcement
and social norms type programs seem to be more successful than simple knowledge-
based campaigns. These former social campaigns include curricular components on
the short-term health consequences of smoking combined with information on the
social influences that encourage smoking. Training on how to resist the pressures to
smoke was also included.

The authors noted that, in addition to considering the specific components that should
be included in a campaign, other significant issues need to be addressed. These
include training given to teachers who deliver the campaign, and research on how
well each component is delivered and implemented. This information is important in
assisting effectiveness. Consideration must also be given to the age of young people
targeted.

Mass media campaigns:
Mass media campaigns can influence smoking behaviour but have limited
effectiveness. Both the intensity and duration of the messages delivered appear to be
important factors. In evaluating these campaigns, the authors noted difficulties with
evaluation research methods such as high dropout rates, and differences between
groups in baseline smoking rates.

Regulation:
Enforcement of the law relating to cigarette sales to underage youth can have an effect
on retailer behaviour but the impact on smoking behaviour is likely to be small.
Community approaches involving different intervention components can influence
smoking behaviour, particularly when multiple sites within a community are targeted.

Community campaigns:
Despite methodological problems in evaluation, there is some limited support for the
effectiveness of community programs to prevent the uptake of smoking in young
people. Although there were few similarities across studies in terms of individual
components, two studies that were successful in influencing smoking rates both
targeted multiple sites within the community (such as schools, work sites and
churches). Differing media were used simultaneously in order to reinforce messages.

Community interventions are likely to be influenced by local factors and are therefore
difficult to replicate in other settings. Specific components, however, involving
schools, work-places, the media and other community groups, can be modified so as
to achieve acceptability with identified target groups.

Most programs have targeted 11 to 17 year olds. Yet attitudes to smoking and
experimentation with cigarettes may already be established by this time. The

108
implementation of programs before regular patterns of smoking behaviour are formed
should be considered, which may even involve targeting children as young as 4 to 8
years of age.

The report argued that prevention programs should be aimed at the social factors that
influence decisions to smoke, and provide training to develop the skills necessary to
resist the social pressures to smoke and drink alcohol. The importance of the school
environment needs to be recognised and schools should aim to create supportive
environments for their pupils. Parents and other community members should be
encouraged to participate in local initiatives so as to create consistent messages.
Campaigns to encourage smoking cessation, as well as targeting smoking prevention,
could be developed. Mass media campaigns can be used to reinforce anti smoking
messages.
Dobbins et al (1996)
The effectiveness of community-based health projects: A
systematic review.
This report aimed to summarise evidence about the effectiveness of community based
heart health campaigns in public health nursing practices in Canada. The review
focused on campaigns where community involvement is used in implementing
strategies. The campaigns had a clear theoretical framework (social learning theory,
diffusion of innovation theory) and involved the mass media, health campaigns and
screening clinics. [The method of selecting studies is included in the review].

There is a wide diversity of evaluation research reviewed and it is difficult to
generalise. Seventeen heart health projects were included in the review.

The authors concluded that community-based initiatives can have positive effects on a
variety of heart health outcomes such as decreased smoking rate, increased physical
activity level, smoking cessation, weight loss, decreased risk assessment score,
decreased blood pressure, and decreased serum cholesterol level. Outcome measures
that were most positively affected were program process measures, health risk
behaviour change, and physical health status.

There was evidence to support the use of multiple strategies that include mass media
and issue-specific health classes. The findings of the review, however, demonstrated a
diminishing effect over a period of time greater than 10 years.
Shepherd et al (1999)
Interventions for encouraging sexual lifestyles and behaviours
intended to prevent cervical cancer. Cochrane Review.
The report evaluated the effectiveness of health education campaigns promoting
sexual risk reduction behaviours among women to reduce transmission of HPV,
which is one of the major risk factors for cervical cancer. [The method of selecting
studies is included in the report].

All studies reviewed had the primary aim of preventing HIV and other STDs rather
than cervical cancer per se. Of the studies evaluated, all showed a statistically
significant positive effect on sexual risk reduction, typically with increased use of

109
condoms. This positive effect was generally sustained up to three months after
intervention. Factual information provision delivered with sexual negotiation skill
development is more effective in comparison to no treatment or groups receiving
generic health promotion.

The report concluded that educational campaigns, in which information provision is
complemented by development of sexual negotiation skills, and targeted at socially
and economically disadvantaged women, can encourage at least short-term sexual risk
reduction behaviour. This has the potential to reduce the transmission of HPV, thus
possibly reduce the incidence of cervical carcinoma. Thus, health education
interventions in which factual information on STD transmission and prevention is
presented alongside skill development and motivation building can achieve short-
term increases in reported condom use for vaginal intercourse.

The report noted that information provision is a useful first step, but factors such as
attitudes, motivation, the influence of significant others, wider social influences, as
well as practical skills, all play an important part in the ability to change behaviour.

The findings of this review are similar to those conducted by Windgood et al (1996)
that examined a range of sexual risk reduction interventions. This report found that
successful interventions were those that were based upon socio-psychological models
of behaviour, paid attention to gender issues in the negotiation of safer sex, employed
peer educators and used multiple intervention sessions.

The report recommended greater attention to gender and culture issues, greater
integration between sexual health and cervical cancer information, and longer time
spans for interventions.

Paul, C. & Redman, S. (1997)
A review of the effectiveness of print material in changing health-
related knowledge, attitudes and behaviour.
The report identifies five review papers and 43 studies that met the defined inclusion
criteria. [The method for including studies is included in the paper].

The authors conclude that pamphlets are potentially effective in changing knowledge,
attitudes and behaviour for a wide range of health related issues, but the evidence is
very mixed.

They argue that effectiveness varies according to three factors. Pamphlets were more
likely to be effective when used for patient education than in public education. The
effects on behaviour varied according to whether a pamphlet was used alone or as an
addition to another form of intervention. Pamphlets appeared to be more consistent in
changing knowledge and attitudes than changing behaviour.

110
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