Effectiveness and confusion of the Time to Change anti-stigma campaign

Stigma is a social construction that devalues people because of a distinguishing characteristic or mark. The World Health Organization and the World Psychiatric Association recognise that the stigma attached to mental disorders is strongly associated with suffering, disability and poverty. Stigma is also a major barrier to seeking treatment. Many studies show that negative attitudes towards the mentally ill are widespread, while the media ORIGINAL PAPERS

Stigma is a social construction that devalues people because of a distinguishing characteristic or mark. 1 The World Health Organization and the World Psychiatric Association recognise that the stigma attached to mental disorders is strongly associated with suffering, disability and poverty. 2 Stigma is also a major barrier to seeking treatment. 3Many studies show that negative attitudes towards the mentally ill are widespread, while the media Aims and method Several national anti-stigma campaigns have been devised in the UK, including the current Time to Change campaign in England.Our aim was to assess whether the campaign promotional materials were likely to have any effect on public attitudes towards mental illness.Postcards, leaflets and bookmarks promoting the campaign were posted to 250 participants recruited from a representative panel of members of the public.Two weeks later a questionnaire was sent to assess the impact the campaign materials had.

Results
The response rate was 78%.Only 23% of participants recognised the Time to Change logo after 2 weeks and only 20% correctly reported that one in four people were affected by mental health problems when presented with five alternative responses.Almost as many participants thought the campaign was promoting a British political party rather than discrimination against mental illness.
Clinical implications A single exposure to Time to Change campaign materials is unlikely to be effective.The title of the campaign is likely to be confused with political campaigning in Britain.

Declaration of interest None.
generally depict mentally ill people as violent, erratic and dangerous. 4,50][11] These methods have been the basis of several anti-stigma campaigns.For example, the Royal College of Psychiatrists' Changing Minds campaign aimed to promote positive images of mental illness, challenge misrepresentations and discrimination, and educate the public to the real nature and treatability of mental disorder. 5This campaign contributed towards Action on Mental Health: A Guide to Promoting Social Inclusion, a document of 12 fact sheets on reducing the stigma of mental illness, with practical advice to health agencies, employers and stakeholders. 12More recently, national anti-stigma campaigns have been launched in Scotland (www.seemescotland.org.uk) and England (www.time-to-change.org.uk).4][15] These reports discuss the disappointing results from the English Defeat Depression and Changing Minds campaigns and the (Scottish) See Me campaign.
We wanted to assess whether promotional materials from the Time to Change campaign (postcards, leaflets and bookmarks) were likely to have any effect on public attitudes towards mental illness.

Participants
We identified a panel of 250 participants from the UK general population recruited using direct mail-shots and adverts in local newspapers as described in a previous study. 16

Procedure
Each participant was posted a Time to Change postcard, leaflet and bookmark, where it was clearly stated that mental health problems affect '1 in 4 people'.Two weeks later a questionnaire was posted out (see online supplement to this article).The attitude of participants towards mental illness was tested using the 5-item Attitude to Mental Illness Questionnaire (AMIQ), with a vignette describing a man with depression and an episode of self-harm.The questionnaire also enquired about participants' gender, age, ethnicity and employment status, recognition of the Time to Change logo, awareness of the '1 in 4' slogan and the purpose of the Time to Change campaign.

Instruments
The 5-item AMIQ is a brief self-completion questionnaire. 16,17Respondents read a short vignette describing an imaginary patient and answered five questions relating to it (online supplement).The questions were scored on a 5-point Likert scale (maximum + 2, minimum72), with blank questions, 'neutral' and 'don't know' scoring zero.The total score for the vignette ranged between 710 and + 10.The AMIQ has been shown to have good psychometric properties in a sample of over 800 members of the UK general public (one component accounted for 80.2% of the variance; test-retest reliability was P = 0.702; alternate testreliability v. Corrigan's attribution questionnaire was 0.704 (Spearman's Rho); Cronbach's a = 0.93). 16

Results
Completed questionnaires were received from 196 individuals (response rate 78%); 32% were male; mean age was 50 years (s.e.= 1.1); 56% were in paid employment; 92% described themselves as White British; 41% endorsed the item 'Do you know anyone personally who has a serious mental illness (like schizophrenia) or someone who has been in a mental hospital?' The mean score was +1.92 (s.e.= 0.29; s.d.= 2.91) for the 5-point AMIQ stigma scale.We compared this with a score from the AMIQ validation 3 years earlier on 1098 members of the UK general public: + 2.35 (s.e.= 0.10). 16There was no statistically significant difference in scores (Mann-Whitney U-test two-sided P = 0.0367; power (for 5% significance) = 55%).

Campaign recognition
The campaign logo was recognised by 23% of participants.However, only 17% stated that they had ever heard of the Time to Change campaign.Only 20% correctly reported that one in four people were affected by mental health problems when presented with five alternative responses (33% chose one in three; 14% one in five; 12% one in six; and 34% did not know).When asked 'What issue or organisation does the Time to Change campaign promote?' and presented with six alternatives, 24% correctly identified 'discrimination against mental illness'.However, 57% endorsed 'Don't know/None of the above,' and 20% endorsed 'The Liberal Party'.

Familiarity with mental illness
Overall, 82 (42%) participants had contact with a mentally ill person.Still, familiarity with mental illness had no significant effect on the AMIQ stigma scores or familiarity with the campaign.The 45 participants who recognised the campaign logo had a significantly increased chance of correctly identifying the objective of the campaign (Yatescorrected w 2 = 6.95;P = 0.0084; OR = 2.74 (95% CI 1.34-5.6)),but they had a reduced chance of identifying the '1 in 4' catchphrase (Yates-corrected w 2 = 0.02; P = 0.8983; OR = 0.88 (95% CI 0.4-1.93)).

Discussion
A single exposure to three forms of promotional materials from the Time to Change anti-stigma campaign (postcards, leaflets and bookmarks) had little discernable effect on public attitudes towards mental illness.There was no significant change on scores of the AMIQ when performed in respect to a fictitious man with depression who self-harmed.
Only a minority of participants (less than 25%) recognised the logo, the name of the campaign, the '1 in 4' message and the campaign objective.This was despite the fact that three brief items of campaign materials had been posted directly to participants only 14 days before the questionnaire.There also seemed to be significant confusion between the anti-stigma Time to Change campaign and campaigns by British political parties.For example, the Conservative Party is currently using several variations on the 'time to change' themes in its marketing -'vote to change', 'election to change'; online Fig. DS1).This was topical at the time of the survey (April 2009) in the run up to the European Parliament elections in June that year.A similar message is being promoted by most British political parties, including the Liberal Democrats.Almost as many participants believed that the Time to Change campaign was being used to promote the 'Liberal Party' and that its objective was to reduce discrimination towards mental illness (20% v. 24%).As the political campaigns are likely to intensify rather than diminish in the run up to the next UK general election (which must take place on or before June 2010), this is likely to increase the confusion and reduce the effectiveness of the Time to Change anti-stigma campaign.
A second problem of the Time to Change campaign is common to all promotional campaigns, including those of political parties and commercial product advertising.The general public is saturated with promotional literature and it is extremely difficult to get noticed and transmit any message. 18,19Even factual stories in newspapers have little impact (e.g. on voting behaviour).Consequently, marketing campaigns and newspapers tend to associate their products or stories with publicly recognised celebrities. 18,20Although the Time to Change campaign is endorsed and promoted publicly by celebrities such as Stephen Fry and Ruby Wax, they were not present on the materials used in our study.
It is unlikely that a single exposure to Time to Change materials would be effective.Although attempting to ensure repeated regular exposure over many months is prohibitively expensive, this is likely to be the only means of effecting significant 'market penetration' and attitude change.
There are now many suggested means of reducing the stigma of mental illness, including Action on Mental Health 12 and Changing Minds. 14However, responses to these campaigns tend to be small, especially if negative consequences of mental illness are also disseminated. 21infold et al 22 reported a project in which 472 English secondary school children attended mental health awareness workshops.Knox et al 23 studied addressing stigmatised attitudes to mental illness among 4 million members of the US armed forces, which involved mandatory training on recognition of mental illness.Although this significantly reduced suicide rates, there was no effect on stigmatised attitudes.It was possible in a military or secondary school setting to insist on engagement in anti-stigma training.By contrast, involvement of the general public in any campaign is entirely voluntary.
Promoting direct interpersonal contact with people who are mentally ill may be an effective strategy, but the amount of contact required remains unknown. 6,11,23,24There was no significant effect of personal familiarity with a mentally ill person and stigmatised attitudes in our study, despite the fact that almost half of the respondents reported some familiarity with mental illness.This was also noted in an earlier study which showed no difference in the attitude of participants to people with alcoholism and those with opiate dependence, despite the fact that alcohol problems are several times more common in Britain than opiate dependence. 25This argues against the anti-stigmatising effect of direct contact with people with certain mental illnesses.Furthermore, it would be difficult in practice to ensure that a significant proportion of the public had contact with people with a severe mental illness.

Study strengths and limitations
The AMIQ was used in this study as it is convenient and has been well validated. 16,17,25Other instruments are available, although they tend to be much longer, involve interviews or tend to address the experience of stigma by people with mental illness themselves (e.g. the Internalised Stigma of Mental Illness scale). 16,27lthough there were more female respondents, age and employment status of participants were reasonably matched to that from UK census surveys and the sample appears to be a reasonable cross-section of the British public.However, the sample was self-selecting and may not generalise across the whole population.Ideally, interviews could be conducted using a quota survey of households with repeat visits for non-responders. 5Unfortunately, this is prohibitively expensive.
The study presented a hypothetical person who was mentally ill.This is less accurate than real experience.Moreover, the written views and expressed attitudes may not translate into any enduring behavioural change.It was not possible to measure stigmatised behaviour towards real people who are mentally ill.
There was no direct contact between participants and researchers, but participants are likely to make some assumptions about the potentially liberal beliefs of researchers into mental health.Hence social desirability bias may affect the results.However, the results from previous studies using the AMIQ suggest that participants had little reservation about indicating their disapproval of people with stigmatising illnesses such as substance use disorders. 16,25This would indicate that social disability bias has only a modest effect.ORIGINAL PAPERS

Dr
Abu Abraham, MB BS, MD, DipCP, MRCPsych, is Specialty Trainee in General Adult Psychiatry at the Mental Health Unit, Basildon Hospital, Nethermayne; Dr Joby Maducolil Easow, MB BS, is Staff Grade Psychiatrist (Specialty Doctor) at the Community Drug and Alcohol Service, Pitsea; Dr Palanisamy Ravichandren, MB BS, MRCPsych, is Specialty Trainee in Psychiatry, Runwell Hospital, Wickford; Dr Salman Mushtaq, MB BS, MRCPsych, is Specialty Trainee in General Psychiatry, The Taylor Centre; Linda Butterworth is a researcher at Southend Community Drug and Alcohol Service, The Taylor Centre; Dr Jason Luty, PhD, MRCPsych, is Consultant in Addictions Psychiatry, South Essex Partnership NHS Trust, and Honorary Consultant in Addictions Psychiatry, Cambridge and Peterborough Mental Health NHS Trust, The Taylor Centre, Southend-on-Sea, UK.