The British Journal of Psychiatry (2013)

202, s77–s88. doi: 10.1192/bjp.bp.113.126672

Influence of Time to Change’s social marketing

interventions on stigma in England 2009–2011
Sara Evans-Lacko, Estelle Malcolm, Keon West, Diana Rose, Jillian London, Nicolas Rüsch,
Kirsty Little, Claire Henderson and Graham Thornicroft

Background
England’s Time To Change (TTC) social marketing campaign not for knowledge or attitudes. Campaign awareness was
emphasised social contact between people with and without positively associated with greater knowledge (b = 0.80, 95%
mental health problems to reduce stigma and discrimination. CI 0.52–1.08) and more favourable attitudes (commonality
OR 1.37, 95% CI 1.10–1.70; dangerousness OR 1.41, 95% CI
Aims 1.22–1.63) and intended behaviour (b = 0.75, 95% CI 0.53–
We aimed to assess the effectiveness of the mass media 0.96). Social contact at events demonstrated a positive
component and also that of the mass social contact events. impact (M = 2.68) v. no contact (M = 2.42) on perceived
attitude change; t(211) = 3.30, P = 0.001. Contact quality
Method predicted more positive attitude change (r = 0.33, P50.01)
Online interviews were performed before and after each and greater confidence to challenge stigma (r = 0.38, P50.01).
burst of mass media social marketing to evaluate changes
in knowledge, attitudes and behaviour and associations Conclusions
between campaign awareness and outcomes. Participants at The favourable short-term consequences of the social
social contact events were asked about the occurrence and marketing campaign suggest that social contact can be
quality of contact, attitudes, readiness to discuss mental used by anti-stigma programmes to reduce stigma.
health and intended behaviour towards people with mental
health problems. Declaration of interest
G.T. has received grants for stigma-related research in the
Results past 5 years from Lundbeck UK and from the National
Prompted campaign awareness was 38–64%. A longitudinal Institute for Health Research, and has acted as a consultant
improvement was noted for one intended behaviour item but to the UK Office of the Chief Scientist.

Social marketing campaigns are being used increasingly as a way which people with mental health problems experienced stigma
to reach the public, to modify health or prosocial behaviours and discrimination, from whom they experienced it, and what
and to promote specific health issues. In view of the high costs should be done. In-depth interviews with survey respondents were
of such campaigns, it is important to understand how far they used to identify attitudes to mental illness that contributed to
can make a significant population impact, to characterise the most stigma and discrimination. Focus groups and interviews with
effective and efficient delivery of messages to mass groups, and to the target audience were conducted throughout the campaign
evaluate the overall strengths and weaknesses of social marketing period, and campaign messages were tailored according to what
interventions in contributing to health improvements.1 The Time resonated best with the target group.
to Change (TTC) programme, launched in January 2009,2 aimed
to make significant improvements across England in public
attitudes and to achieve less discriminatory behaviour in relation Target audience
to people with mental illness. One component of the programme The campaign media targeted men and women in their mid-20s to
was the anti-stigma social marketing campaign, which engaged mid-40s, from middle-income groups. A broad target group was
the public through mass media channels, calls to action and selected in order to reach a high proportion of individuals. The
participation in mass social events. We assessed its effectiveness campaign was aimed primarily at those who had some proximity
in improving public knowledge, attitudes and behaviour in to people with mental health problems, not as close family
relation to people with mental illness over a 2.5-year period members but as friends, colleagues and wider family. Based on
between January 2009 and August 2011. insights during the campaign development phase, individuals
were categorised into groups termed ‘active discriminators’,
Method ‘subconscious stigmatisers’ and those who are ‘unaware of mental
illness’. Members of the ‘unaware’ group were not main targets as
Campaign development they might not feel that a campaign discussing mental health
The anti-stigma social marketing campaign was developed by a issues was relevant to them. Although their behaviour was
team of individuals working with TTC including people using extreme, it was felt that people in the ‘active discriminators’ group
mental health services and individuals with expertise in such would be difficult to target, constitute a small number of
campaigns. Researchers from the Institute of Psychiatry, London, individuals and seem unacceptable in mainstream society; thus,
acted as the independent evaluators and did not participate in the although this group was not chosen as a specific target of the
intervention development or delivery. Initially a survey (‘Stigma social marketing campaign, it could be influenced indirectly by
Shout’) of almost 4000 people with direct experience of mental the target group of ‘subconscious stigmatisers’ as they became
health problems was conducted, followed by workshops with over more active in challenging stigma and discrimination. Thus, in
100 survey participants. These activities explored situations in terms of attitudes, the campaign’s primary target audience was

s77
Evans-Lacko et al

those termed ‘subconscious stigmatisers’: people who do not to promote social contact between people with and without
recognise that discrimination against people with mental health mental health problems.
problems happens, or how their actions might contribute to this.
Thus, the overall target group was one that included a significant
Study participants
proportion of the public, may indirectly influence other groups,
and may have attitudes most amenable to a social marketing The mass media and social contact events were evaluated
campaign. separately using different sets of participants.

Mass media component

Campaign media and messages
Participants were recruited through an online market research
Each year there were two main bursts of social marketing activity
panel (900–1100 participants per burst). Previous work suggests
including some or all of national television, print, radio, cinema,
that behavioural intentions towards people with mental health
outdoor and online advertisements. All advertising campaigns
problems may be better assessed using online self-complete
were supported by public relations and media work to maximise
methods rather than in-person interviews.3 The sample was
unfunded editorial coverage. Campaign reach was extended by
restricted to the campaign target population (i.e. residents of
working in partnership with stakeholder organisations (e.g.
England aged 25–45 years and of middle-income groups). Quotas
National Health Service trusts) across England and making
were set for each type of media used to enhance the likelihood that
campaign materials freely available. Social media included
survey participants were exposed to campaign materials. Online
Facebook, Twitter and YouTube, as these were the sites most used
panel interviews took place before and after each burst of
by the target audience. Advertising directed the target audience to
campaign activity. Quotas were also set to include equal
the TTC website, which includes stories of people with mental
distributions of age, gender and socioeconomic status, and the
health problems, tips for what people can do to fight stigma, blogs
sample was designed to be geographically representative of the
and forums (www.time-to-change.org.uk). The campaign focused
population in England. Ethnic minority participants were
on behaviour change, using social media to drive the target group
oversampled to ensure that we had sufficient statistical power to
to action (i.e. from small actions, such as starting a conversation
analyse this subgroup.
about mental health with a friend or co-worker, to helping
organise a local event aimed at engaging the community or
organisations in fighting stigma and discrimination against people Social contact component
with mental health problems). Social media incorporated inter- Participants were adults who attended a social contact event in
active online content, suggested simple ways to change behaviour different cities around England and had a conversation with a
and recruited individuals to engage in local campaign activities. volunteer. In total 725 participants – 192 men and 519 women,
Year 1 activity (2009) used a myths/facts message to get 14 of undisclosed gender, mean age 38.1 years (s.d. = 14.1) –
discrimination against people with mental health problems on completed a questionnaire.
the public agenda and improve knowledge relevant to stigma. Year
2 focused on attitudes, emphasising recognition of one’s own
prejudice, including the hard-hitting ‘Schizo movie’ advert to Measures
encourage people to recognise their own stereotypes about The National Institute for Health and Clinical Excellence
schizophrenia (www.youtube.com/watch?v = 6IBgkks_jLw). During emphasises the inclusion of knowledge, attitude and behavioural
year 3, the ‘Time to Talk’ campaign was introduced to encourage components when developing and evaluating interventions aimed
the target audience to start a conversation about mental health at behaviour change among individuals or populations.4
and to facilitate social contact between people with and without Therefore, in addition to measuring prompted campaign
mental health problems. Each year’s campaign was developed awareness and message communication, our evaluation included
applying the results of evaluations of the previous ones. outcome measures of mental health-related knowledge, attitudes
and behaviour. Additional measures were tailored for the
evaluation of the mass media (e.g. campaign awareness) v. social
Mass participation social contact events contact events (quality and quantity of social contact), as
During 2011, alongside the Time to Talk campaign and call to described below.
action, social contact events were developed in partnership with
local organisations to provide real-life opportunities to talk about
Mass media component
mental health problems and to act on the messages delivered by
the Time to Talk campaign. Some social contact events were Campaign awareness. Spontaneous (unprompted) awareness
embedded within existing festivals or took place in town centres was assessed by the question, ‘Can you think of any campaigns
with high levels of pedestrian traffic. These events used a mobile – that is, advertising or events in the local community – you have
living-room set and were staffed by volunteers with experience seen or heard of recently concerning mental health or mental
of mental health problems; these volunteers approached passers- health problems?’. Those who answered positively were then asked
by and encouraged them to take time out and talk about mental to describe everything they remembered seeing, hearing or feeling
health in the comfort of the living-room set. Members of the about the campaign. Answers were coded carefully as pertaining to
public could relax in this setting with a cup of tea or water and TTC or not. Prompted awareness was then assessed for each type
explore the interactive facilities, which included written material of TTC media and/or activity. For example, individuals were asked
designed to educate and improve attitudes about mental health. whether they had seen the television advertisement, seen a similar
Mental health professionals were also available at some events advertisement, or did not know if they had seen it or not.
for members of the public who required further information on Awareness of each type of media communication was assessed
how to access services. Other events were organised specifically separately. Individuals who reported seeing the advertisement
for TTC and incorporated activities or educational resources to were categorised as ‘campaign aware’ whereas those who
engage the public (such as sports, dance, film and music) and responded ‘no’ or ‘don’t know’ were categorised as ‘not campaign

s78
 Influence of social marketing interventions

aware’. Overall campaign awareness was summarised into a binary engage with a member of the ‘outgroup’.17 Assessment of intended
variable (campaign aware: yes/no) for whether individuals reported behaviour allowed for brief and feasible evaluation at the
seeing any of the media. The number of media that each individual population level. Although assessment of actual behaviour is also
was aware of was also tabulated. Campaign awareness associated important, to understand these changes at the population level
with the post-burst interviews pertained to awareness of the would require contextualisation of behaviours (i.e. whether
specific media immediately preceding the survey, whereas individuals chose to live with someone with mental health
awareness during the pre-burst stage referred to recall of the problems, and whether they perceived this as a positive
previous campaign burst. experience). Additionally, because some behaviours might not
be relevant to all participants, we measured intended behaviour
Mental health-related knowledge. Mental health-related knowledge among the public and changes in reported and experienced
was measured using the Mental Health Knowledge Schedule discrimination from the perspective of those using mental health
(MAKS).5 This comprised six items covering stigma-related services.18 Overall test–retest reliability of the RIBS was 0.75 and
mental health knowledge areas (help-seeking, recognition, the overall internal consistency of the scale was 0.85.16
support, employment, treatment and recovery) and six items that
Social contact component
enquired about classification of various conditions as mental
illnesses.6 Overall test–retest reliability of the MAKS was 0.71 Among the social contact event participants, we collected socio-
and the overall internal consistency among items was 0.65.5 demographic information and data on whether they had
experience of mental health problems, social proximity to
someone with a mental health problem, and whether this was
Mental health-related attitudes. Attitudes were assessed based
disclosed during the event. Participants who had met someone
on three items from the UK Department of Health Attitudes to
with a mental health problem were asked to identify the type of
Mental Illness survey. These items were chosen a priori in
problem by choosing one or more of the following categories:
collaboration with the campaign developers and approved by an
depression, eating disorder, schizophrenia, bipolar disorder, drug
expert panel including people using mental health services and
addiction, panic attacks and other.
international stigma experts. They allowed the evaluation results
to be directly compared with the concurrent national Attitudes
to Mental Illness surveys,7 which have used items based on the Contact quality and quantity
Community Attitudes toward the Mentally Ill (CAMI) and The duration of the intergroup contact reported by participants
Opinions about Mental Illness scales since 1993;8,9 see also was measured by asking ‘How long did you speak with the
Evans-Lacko et al, this supplement.10 The items were selected in individual you met?’ (1, less than 10 min; 2, between 10 min and
line with campaign targets and on the basis of their significance 30 min; 3, more than 30 min). Participants indicated the quality
in relation to stigma and discrimination; they assessed attitudes of the contact they experienced by answering three questions,
regarding commonality (‘Virtually anyone can become mentally based on the facilitating conditions theorised by Allport and by
ill’), responsibility (‘People with mental health problems should Pettigrew & Tropp,19,20 on three-point response scales (1, no; 2,
not be given any responsibility’) and dangerousness (‘People with yes, a little; 3, yes, a lot): ‘Do you feel you got to know the person?’,
mental health problems are far less of a danger than most people ‘During the event did you feel like you were actively working
suppose’). All items addressed messages that were explicitly together?’ and ‘Do you feel like you were both able and willing
targeted by the campaign: for example, the ‘one in four’ message to achieve that goal?’. This scale did not attain the conventional
was a part of the myths/facts campaign and addressed commonality; level of reliability (a = 0.55); however, as item deletion did not
the ‘Schizo movie’ advert aimed to challenge stereotypes about mental improve scale reliability we retained all three items.
illness and dangerousness; and the personal testimonials of people
with mental illness demonstrated real stories of empowerment. Attitude change. We measured change in participants’ attitudes
The choice of attitude items was based on previous research towards people with mental health problems in relation to the
and the priorities of the campaign. Attitudes related to common- social contact event specifically using a single item (to maximise
ality and responsibility have been shown to be amenable to a social the response rate): ‘Do you feel that your attitude towards people
marketing intervention.11 Additional research has shown that with mental health problems has changed?’ (1, yes, more negative;
increasing awareness of depression was associated with an increase 2, no, same; 3, yes, more positive).
in sensitivity to issues of discrimination.12 Assessment of attitudes
relating to dangerousness was important because previous Disclosure. We measured participants’ hypothetical discomfort
research has suggested that public attitudes about dangerousness with talking about their own mental health problems using
are especially harmful and can lead to discriminatory behaviour two items measured on five-point response scales (1, very
against people with mental illness.13,14 Moreover, Thompson et uncomfortable; 5, very comfortable). We asked, ‘In general, how
al have suggested that attitudes about dangerousness may limit comfortable would you feel talking to a friend or family member
the effectiveness of anti-stigma interventions;15 thus, it was about your mental health?’ and ‘In general, how comfortable
important to assess the malleability of attitudes regarding would you feel talking about your mental health at work?’
dangerousness alongside an anti-stigma campaign. (a = 0.73).

Mental health-related intended behaviour. Intended behaviour Intended behaviour. Intended behaviour was measured using
(the level of intended future contact with people with mental the RIBS (as in the mass media component evaluation).16 As
health problems) was measured using the Reported and Intended we hoped that the intervention would ultimately increase
Behaviour Scale (RIBS).16 We specifically assessed changes in four participants’ confidence to challenge mental health-related stigma,
intended behaviour outcomes (domains comprised living with, we also measured confidence to challenge stigma using a single
working with, living nearby and continuing a relationship with item: ‘As a result of participating in this event, I feel I have more
someone with a mental health problem) which were based on confidence to challenge stigma and discrimination when I see it.’
existing measures of social distance, which assess willingness to (1, not at all; 2, a little; 3, moderately; 4, a lot).

s79
Evans-Lacko et al

Statistical analysis of their ability to handle skewed data, their superior ability to
Statistical analyses using SAS version 9.1 and SPSS version 20 on detect significant mediation effects regardless of the size of main
Windows XP were made separately for the evaluation of the effects and their ability to retain the most power of a test of
impact of the mass media and social contact components of the mediation.29
social marketing campaign.
Results
Mass media component Mass media component
Sample characteristics and associated confidence intervals are The majority of participants were White, married, working and
presented for each campaign burst. The level of overall prompted knew someone with a mental illness across all six bursts (Table
campaign awareness and associated campaign expenditure is also 1). Owing to quota sampling, respondent characteristics were
presented for each burst. Multivariable linear regression models similar between bursts except that during burst 6 there was a
investigated predictors of overall MAKS and RIBS scores. higher proportion of Black and minority ethnic (BME)
Independent variables entered were: campaign awareness (yes/ respondents. Additional BME respondents were recruited during
no), ethnicity (categorical: White, Asian, Black, Mixed or Other), this burst in order to examine campaign awareness among BME
gender, age (continuous), marital status (married: yes/no), subgroups with more precision.
employment status (categorical: employed, i.e. full or part-time
employment or student working full or part-time or not,
unemployed or retired), socioeconomic group (categorical: B, Campaign awareness
C1 or C2), geographic region (London v. other) and degree of Moderate levels of prompted campaign awareness were achieved
familiarity with mental illness/knowing someone with a mental among the target population following each burst of activity
illness (adapted from the ‘level of contact’ report).21 To examine (39%, 44%, 38%, 39%, 59% and 47% respectively). It is
whether there was a consistent pre–post effect, we included a noteworthy that campaign awareness following each burst was
variable indicating whether the assessment occurred before or strongly associated with campaign burst expenditure (r = 0.76,
after the burst of media (pre v. post). Presence of a longitudinal P = 0.08, n = 6), but there was only a trend to significance,
trend was examined by including campaign burst as a covariate probably owing to the small number of data points.
in the model. Multivariable logistic regression models estimated
the odds of responding positively (i.e. agree strongly or agree Predictors of campaign awareness. Predictors of campaign
slightly) to each of the CAMI statements. All CAMI items were awareness varied by burst, because types of media used and
coded so that agreement summarised a less stigmatising response. messages varied over time. The most consistent predictors of
Sampling weights were developed to match characteristics of campaign awareness were knowing someone with a mental health
the sample recruited to the target population in England, problem, Black ethnicity and living in London (relative to not
according to prevalence rates of ethnicity within geographic region living in London). Notably, Black ethnicity relative to White
reported by the Office for National Statistics, and were used in all ethnicity was positively associated with campaign awareness in
analyses. The final regression model applied sampling weights and four out of the six bursts (1, 3, 5 and 6). Asian ethnicity was
inverse probability weights. Inverse probability weighting allows associated with a lower likelihood of being campaign aware
for modelling of independence between exposure to the campaign compared with White ethnicity but only during the first burst.
and stigma outcomes and estimation of causal effects.22–24 For Knowing someone with a mental health problem was also a
each observation a separate inverse probability weight was created. consistent predictor of campaign awareness (bursts 1, 2, 3 and
Inverse probability weights were proportional to the inverse of the 5). Living in London was associated with higher campaign
propensity of campaign exposure. The final model, which awareness during the first four bursts. For two of the six bursts
incorporated both inverse probability weights and sampling (2 and 5), female gender was associated with a higher likelihood
weights, had smaller standard errors and narrower confidence of campaign awareness relative to male gender.
intervals than the model including sampling weights only,
indicating that the model was more parsimonious in addition to
Knowledge, attitude and intended behaviour
accounting for probability of campaign exposure and thus
minimising potential confounding associated with campaign There was no significant longitudinal improvement in overall
exposure. knowledge or intended behaviour over the entire campaign.
Figures 1 to 4 show the knowledge, attitude and behaviour trends
by item. Figure 1 shows trends in knowledge, as measured by the
Social contact component MAKS, over the six bursts. There was a consistent pre-burst to
We investigated the impact of contact (v. no contact) with a post-burst improvement on the MAKS item pertaining to
person with a mental health problem using independent samples psychotherapy: ‘Psychotherapy (e.g. counselling or talking
t-tests. Following the example of previous contact research we therapy) can be an effective treatment for people with mental
created a single index of contact by using the product of the quantity health problems’. In spite of this, this item also demonstrated a
of contact and quality of contact scores25,26 to investigate whether significant overall decline in agreement over the six bursts. For
more contact and contact of higher quality were associated with the MAKS items addressing conceptualisation of mental illness
more positive attitude change, more comfort with disclosure, there was a longitudinal improvement in the responses to items
reported intended behaviour and greater confidence to challenge pertaining to grief and stress, in that there was a decline in the
mental health stigma. We tested whether changed attitudes total target group stating incorrectly that grief or stress is a mental
mediated the relationship between contact and confidence to illness, over the six bursts (Fig. 2). One RIBS intended behaviour
challenge mental health stigma using Preacher–Hayes bootstrap item (‘In the future, I would be willing to live with someone with a
tests as recommended by Zhao et al.27 Bias-corrected bootstrapping mental health problem’) showed consistent improvement among
techniques are favoured over conventional forms of mediation tests the total target population, growing 15 percentage points
(e.g. Sobel’s Z or the methodology of Baron & Kenny28), because (29.3% to 44.4%) over the six bursts (Fig. 3).

s80
 Influence of social marketing interventions

Table 1 Mass media campaign participant characteristics, unweighted ( n = 5615)

Burst 1 Burst 2 Burst 3 Burst 4 Burst 5 Burst 6
n = 1110 n = 908 n = 907 n = 913 n = 909 n = 868

Gender, n (%)
Male 551 (49.6) 455 (50.1) 436 (48.1) 441 (48.3) 458 (50.4) 370 (42.6)
Female 559 (50.4) 453 (49.9) 471 (51.9) 472 (51.7) 451 (49.6) 498 (57.4)
Socioeconomic group, n (%)
B 365 (32.9) 313 (34.5) 317 (35.0) 330 (36.1) 325 (35.8) 326 (37.6)
C1 384 (34.6) 323 (35.6) 327 (36.1) 328 (35.9) 327 (36.0) 347 (40.0)
C2 361 (32.5) 272 (30.0) 263 (29.0) 255 (27.9) 257 (28.3) 195 (22.5)
Age, years: mean (s.d.) 34.8 (5.7) 34.6 (5.7) 34.8 (5.9) 34.6 (5.8) 34.5 (5.8) 34.4 (5.8)
Ethnic group, n (%)
Asian 192 (17.3) 159 (17.5) 164 (18.1) 195 (21.4) 166 (18.3) 266 (30.6)
Black 70 (6.3) 65 (7.2) 59 (6.5) 28 (3.1) 46 (5.1) 78 (9.0)
Mixed 43 (3.9) 40 (4.4) 39 (4.3) 37 (4.1) 44 (4.8) 74 (8.5)
Other 10 (0.9) 7 (0.8) 13 (1.4) 15 (1.6) 14 (1.5) 18 (2.1)
White 795 (71.6) 637 (70.2) 632 (69.7) 638 (69.9) 639 (70.3) 432 (49.8)
Children, n (%)
Yes 634 (57.1) 513 (56.5) 458 (50.5) 533 (58.4) 498 (54.8) 486 (56.0)
No 476 (42.9) 395 (43.5) 449 (49.5) 380 (41.6) 411 (45.2) 382 (44.0)
Married, n (%)
Yes 841 (75.8) 681 (75.0) 662 (73.0) 683 (74.8) 650 (71.5) 635 (73.2)
No 269 (24.2) 227 (25.0) 245 (27.0) 230 (25.2) 259 (28.5) 233 (26.8)
Employment status, n (%)
Student 18 (1.6) 11 (1.2) 9 (1.0) 18 (2.0) 13 (1.4) 9 (1.0)
Working 980 (88.3) 764 (84.1) 789 (87.0) 781 (85.5) 804 (88.4) 760 (87.6)
Not working 112 (10.1) 133 (14.6) 109 (12.0) 114 (12.5) 92 (10.1) 99 (11.4)
London resident, n (%)
Yes 318 (28.6) 174 (19.2) 190 (20.9) 187 (20.5) 186 (20.5) 267 (30.8)
No 792 (71.4) 734 (80.8) 717 (79.1) 726 (79.5) 723 (79.5) 601 (69.2)
Social proximity to mental illness, n (%)
Yes 836 (75.3) 714 (78.6) 703 (77.5) 689 (75.5) 673 (74.0) 644 (74.2)
No 274 (24.7) 194 (21.4) 204 (22.5) 224 (24.5) 236 (26.0) 224 (25.8)

Campaign awareness and total knowledge score Campaign awareness and attitudes
Table 2 presents the predictors of total knowledge score (MAKS Table 3 presents the predictors of agreement to the three CAMI
items 1–6). Model 1(a) incorporates sampling weights only and items (commonality, responsibility and dangerousness). All CAMI
model 2(a) incorporates inverse probability and sampling weights. items were coded so that greater agreement summarised a less
For both models campaign awareness was a significant predictor of stigmatising response. Campaign awareness was a significant
better knowledge. Other significant predictors of better knowledge predictor of agreement (i.e. less stigmatising attitude) with the
included being of female gender, higher socioeconomic group commonality and dangerousness items; however, there was no
and social proximity to people with mental health problems. significant association with the responsibility item. Other
Being of Asian ethnicity was associated with having a lower significant predictors of agreement with the commonality item
knowledge score in model 1(a) but not 2(a). included female gender, older age and social proximity to mental

90 –

0 0 Employment
80 – 0
0 0 0 0
0 0 0 0 0 Advice to a friend
0 0 0 0 0 0 0
70 – 0 0 0 0 0 0 0
0 0 0
0 0 0 Medication
0 0 0 0 0
60 – 0 0 Psychotherapy
Score

0
50 – 0 0 Recover
0 0 0
0 0 0 0 0
0 0 0 0 0 0 0 Go to their doctor
40 – 0
0 0 0

30 – 0 0
0 0 0 0 0 0 0
0 0 0
20 –
Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post
Burst 1 Burst 2 Burst 3 Burst 4 Burst 5 Burst 6

Fig. 1 Trends in agreement with Mental Health Knowledge Schedule items (part 1) for total target population, January 2009 to August 2011.
Multivariable regression models were fitted for each item and the overall slopes and P-values of the ‘trend’ line associated with each item are
as follows: employment slope 70.04, P = 0.06; advice to a friend 0.02, P = 0.47; medication 0.04, P = 0.08; psychotherapy 70.06, P = 0.01;
recover 0.01, P = 0.63; go to their doctor 70.02, P = 0.39. All items are coded so that higher scores indicate better knowledge.

s81
Evans-Lacko et al

100 –

0 0 0 0
0 0 0 0 0 0 0 0 0 0
0 0 Depression
90 – 0 0 0 0 0
0 0 0
0 0 0 0 Stress
0 0 0 0 0 0 0
80 – 0 Schizophrenia
0 Bipolar disorder
70 –
0 Drug addiction
60 – Grief
Score

50 –

0 0
0
40 – 0 0 0 0
0 0 0 0 0
30 – 0 0 0 0 0 0
0 0 0 0
0 0 0
0 0
0 0 0 0 0 0
20 – 0 0 0

10 –
Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post
Burst 1 Burst 2 Burst 3 Burst 4 Burst 5 Burst 6

Fig. 2 Trends in agreement with Mental Health Knowledge Schedule items (part 1) for the total target population, January 2009 to August
2011. Multivariable regression models were fitted for each item and the overall slopes and P-values of the ‘trend’ line associated with
each item are as follows: depression slope 70.03, P = 0.24; stress 70.07, P = 0.003; schizophrenia 70.07, P = 0.07; bipolar disorder 0.01,
P = 0.71; drug addiction 0.02, P = 0.44; grief 70.07, P = 0.002. All items are coded so that higher scores indicate better knowledge.

100 –
0 Live with
0 Work with
0 Live nearby

80 – 0 Continue a relationship
0 0 0 0 0
0 0 0
0 0 0
0 0 0
0
0 0 0 0
0 0 0 0 0
0 0 0 0 0 0 0
Score

60 – 0 0 0
0

0 0
0 0 0 0
40 – 0 0
0
0
0
0

20 –
Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post
Burst 1 Burst 2 Burst 3 Burst 4 Burst 5 Burst 6

Fig. 3 Trends in agreement with Reported and Intended Behaviour Scale intended behaviour items for total target population, January 2009
to August 2011. Multivariable regression models were fitted for each item and the overall slopes and P-values of the ‘trend’ line associated
with each item are as follows: ’live with’ slope 0.11, P50.0001; ‘work with’ 0.03, P = 0.19; ‘live nearby’: 0.03, P = 0.20; ‘continue a relationship’
70.02, P = 0.43.

health problems; other significant predictors of a less stigmatising only and model 2(b) incorporates inverse probability and
response to the responsibility item included female gender, higher sampling weights. For both models campaign awareness was a
socioeconomic group and social contact with people with mental significant predictor of better intended behaviour. Other
health problems. Being of Asian, Black or Other ethnicity and having significant predictors of better intended behaviour included
children was associated with more stigmatising attitudes on all three higher socioeconomic group, younger age and social proximity
items. Other significant predictors of a less stigmatising response to to people with mental health problems. Being of Asian, Black or
the dangerousness item included female gender, higher socioeconomic Other ethnicity relative to White ethnicity and living in London
group, older age and social proximity to mental health problems. were associated with more negative intended behaviour.

Campaign awareness and intended behaviour Social contact component

The predictors of total intended behaviour (RIBS) score are In total 725 participants spoke to a volunteer before completing
presented in Table 2. Model 1(b) incorporates sampling weights measures of contact duration, contact quality, disclosure, attitude

s82
 Influence of social marketing interventions

100 –

90 – 0 0
0 0
0 0 0 0 0 0
0 0
80 –

0 Commonality
Score

70 –
0 0 0 Responsibility
0
0
60 – 0 0 0 0 Dangerousness
0 0 0
0 0 0
0 0 0
0 0 0
50 – 0 0
0 0 0

40 –
Pre Post Pre Post Pre Post Pre Post Pre Post Pre Post
Burst 1 Burst 2 Burst 3 Burst 4 Burst 5 Burst 6

Fig. 4 Trends in agreement with Community Attitudes toward the Mentally Ill items for total target population, January 2009 to August
2011. Multivariable regression models were fitted for each individual item and the overall slopes and P-values of the ‘trend’ line associated
with each item are as follows: commonality slope 0.0, P = 0.61; responsibility 70.04, P = 0.06; dangerousness 70.001, P = 0.91. All items
are coded so that higher scores indicate better knowledge.

change, campaign engagement and intended future behaviours. Of allow us to determine what impact, if any, the contact had,
these 725 participants, 34% (n = 246) identified themselves as not regardless of its duration or quality. The results in Table 4 suggest
having a mental health problem (75 men, 168 women (3 respondents a significant effect of contact on perceived attitude change and
did not indicate their gender); mean age 35.1 years, s.d. = 17.7); comfort in talking about one’s own (hypothetical) mental health
these participants were used in the analyses. problems. Participants who had experienced contact were also
more confident to challenge stigma compared with those who
Impact of contact v. no contact had not, although this difference was not significant at the 5%
We first tested the impact of having contact with someone with a level (P = 0.1). We found no difference in intended future
mental health problem by comparing participants who had behaviour between participants who had experienced contact
experienced such contact with those who had not. This would and those who had not.

Table 2 Predictors of total Mental Health Knowledge Schedule and Reported and Intended Behaviour Scale scores, January 2009
to September 2011 ( n = 5615) a
MAKS RIBS
Model (1a) Model 2(a) Model 1(b) Model 2(b)
Sample weighting Inverse probability and Sample weighting Inverse probability and
only sample weighting only sample weighting
Estimate (95% CI) Estimate (95% CI) Estimate (95% CI) Estimate (95% CI)

Campaign awareness *0.86 (0.52 to 1.19) *0.80 (0.52 to 1.08) *0.81 (0.59 to 1.02) *0.75 (0.53 to 0.96)
Burst (continuous) 70.01 (70.11 to 0.09) 0.01 (70.08 to 0.08) 0.03 (70.03 to 0.09) 0.04 (70.02 to 0.10)
Pre–post 0.04 (70.30 to 0.38) 70.01 (70.28 to 0.27) 70.22 (70.43 to 70.01) 70.24 (70.45 to 70.03)
Gender (ref. male) *0.62 (0.29 to 0.95) *0.66 (0.38 to 0.93) 0.20 (70.01 to 0.42) 0.22 (0.01 to 0.43)
Socioeconomic group (ref. C2)
B *0.52 (0.11 to 0.94) *0.49 (0.15 to 0.82) *0.27 (0.02 to 0.53) *0.26 (0.01 to 0.51)
C1 0.23 (70.18 to 0.64) 0.17 (70.16 to 0.51) 0.18 (70.08 to 0.43) 0.15 (70.10 to 0.41)
Age (continuous) 0.04 (70.11 to 0.20) 0.08 (70.04 to 0.21) *70.21 (70.31 to 70.12) *70.20 (70.30 to 70.11)
Ethnic group (ref. White)
Asian *70.43 (70.81 to 70.04) 70.42 (71.02 to 0.18) *71.15 (71.61 to 70.70) *71.16 (71.62 to 70.70)
Black 70.58 (71.25 to 0.09) 70.55 (71.56 to 0.45) *70.95 (71.72 to 70.18) *70.94 (71.71 to 70.18)
Mixed 70.52 (71.30 to 0.25) 70.59 (71.75 to 0.57) 70.08 (70.98 to 0.81) 70.11 (71.00 to 0.77)
Other 71.11 (72.72 to 0.50) 71.39 (73.50 to 0.72) *71.57 (73.19 to 0.05) *71.76 (73.37 to 70.14)
Having children (ref. no children) 70.10 (70.47 to 0.27) 70.15 (70.45 to 0.16) 70.20 (70.44 to 0.03) 70.22 (70.46 to 0.01)
Married (ref. unmarried) 70.05 (70.45 to 0.36) 70.01 (70.35 to 0.33) 70.09 (70.35 to 0.17) 70.06 (70.33 to 0.20)
Employment status (ref. ‘not working’)
Student 1.43 (0.39 to 2.47) 1.46 (0.09 to 2.82) 70.30 (71.35 to 0.75) 70.24 (71.28 to 0.81)
Working 0.07 (70.43 to 0.58) 0.09 (70.33 to 0.52) 0.18 (70.14 to 0.50) 0.23 (70.10 to 0.55)
London resident 0.15 (70.21 to 0.52) 0.17 (70.22 to 0.56) *70.51 (70.81 to 70.21) *70.50 (70.80 to 70.20)
Social proximity to mental illness (continuous) *0.60 (0.54 to 0.66) *0.59 (0.54 to 0.64) *0.44 (0.40 to 0.48) *0.44 (0.40 to 0.48)

MAKS, Mental Health Knowledge Schedule; ref., reference; RIBS, Reported and Intended Behaviour Scale.
a. All items are coded so that higher scores indicate less stigmatising views.
*P50.05.

s83
s84
Evans-Lacko et al

Table 3 Predictors of agreement with three items from the Community Attitudes toward the Mentally Ill scale, January 2009 to September 2011 ( n = 5615) a
Commonality Responsibility Dangerousness
Sample weighting Inverse probability and Sample weighting Inverse probability and Sample weighting Inverse probability
only sample weighting only sample weighting only and sample weighting
OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI) OR (95% CI)

Campaign awareness *1.42 (1.15 to 1.75) *1.37 (1.10 to 1.70) 1.14 (0.99 to 1.32) 1.12 (0.97 to 1.30) *1.43 (1.24 to 1.64) *1.41 (1.22 to 1.63)
Burst (continuous) 0.98 (0.93 to 1.04) 0.99 (0.93 to 1.04) 0.96 (0.92 to 1.00) 0.96 (0.92 to 1.00) 0.99 (0.96 to 1.04) 0.99 (0.95 to 1.04)
Pre–post 1.03 (0.84 to 1.25) 0.97 (0.79 to 1.19) 1.07 (0.92 to 1.23) 1.05 (0.91 to 1.22) 1.07 (0.93 to 1.23) 1.07 (0.93 to 1.23)
Gender (ref. male) *1.50 (1.22 to 1.84) *1.49 (1.21 to 1.85) *1.68 (1.46 to 1.94) *1.71 (1.48 to 1.98) *1.21 (1.06 to 1.39) *1.21 (1.05 to 1.39)
Socioeconomic group (ref. C2)
B 1.11 (0.87 to 1.43) 1.07 (0.83 to 1.38) *1.45 (1.21 to 1.72) *1.46 (1.23 to 1.75) *1.23 (1.04 to 1.46) *1.21 (1.02 to 1.43)
C1 1.13 (0.88 to 1.43) 1.08 (0.84 to 1.39) *1.25 (1.05 to 1.48) *1.24 (1.04 to 1.47) 1.02 (0.87 to 1.21) 1.01 (0.85 to 1.20)
Age (continuous) *1.19 (1.09 to 1.31) *1.20 (1.09 to 1.32) 1.01 (0.95 to 1.08) 1.01 (0.95 to 1.08) *1.10 (1.04 to 1.17) *1.11 (1.04 to 1.18)
Ethnic group (ref. White)
Asian *0.62 (0.50 to 0.76) *0.62 (0.50 to 0.77) *0.40 (0.34 to 0.46) *0.39 (0.33 to 0.46) *0.77 (0.66 to 0.90) *0.76 (0.65 to 0.90)
Black *0.58 (0.41 to 0.81) *0.59 (0.42 to 0.83) *0.77 (0.59 to 0.99) *0.74 (0.57 to 0.97) *0.54 (0.41 to 0.70) *0.54 (0.41 to 0.7)
Mixed 1.11 (0.72 to 1.72) 1.12 (0.71 to 1.77) 1.25 (0.92 to 1.71) 1.20 (0.86 to 1.66) 0.83 (0.62 to 1.10) 0.83 (0.62 to 1.10)
Other 0.59 (0.32 to 1.08) 0.57 (0.30 to 1.08) *0.55 (0.33 to 0.92) *0.53 (0.31 to 0.91) 0.75 (0.45 to 1.23) 0.76 (0.45 to 1.30)
Having children (ref. no children) *0.78 (0.62 to 0.98) *0.79 (0.63 to 0.99) *0.65 (0.56 to 0.76) *0.66 (0.56 to 0.77) *0.80 (0.69 to 0.93) *0.79 (0.68 to 0.92)
Married (ref. unmarried) 0.91 (0.71 to 1.16) 0.94 (0.74 to 1.20) 1.02 (0.86 to 1.21) 1.04 (0.88 to 1.25) 1.03 (0.87 to 1.21) 1.05 (0.89 to 1.24)
Employment status (ref. ‘not working’)
Student 0.86 (0.34 to 2.16) 0.88 (0.36 to 2.18) 1.32 (0.68 to 2.56) 1.41 (0.73 to 2.73) 1.55 (0.84 to 2.88) 1.54 (0.83 to 2.86)
Work 0.83 (0.59 to 1.17) 0.90 (0.63 to 1.29) 0.86 (0.69 to 1.08) 0.90 (0.72 to 1.13) 1.01 (0.82 to 1.25) 1.02 (0.82 to 1.26)
London resident 0.95 (0.77 to 1.17) 0.96 (0.78 to 1.19) 0.87 (0.75 to 1.02) 0.87 (0.74 to 1.01) 1.15 (0.99 to 1.33) 1.14 (0.98 to 1.33)
Proximity to mental illness (continuous) *1.20 (1.15 to 1.24) *1.19 (1.15 to 1.24) *1.13 (1.11 to 1.16) *1.13 (1.10 to 1.16) *1.14 (1.12 to 1.17) *1.14 (1.11 to 1.16)

a. All items are coded so that higher scores indicate less stigmatising views.
*P50.05.
 Influence of social marketing interventions

Table 4 Outcome variables according to contact

Contacta No contact
Mean (s.d.) 95% CI Mean (s.d.) 95% CI t d.f. P

Attitude change 2.67 (0.50) 1.67 to 3.68 2.41 (0.53) 1.35 to 3.49 3.30 211 0.001
Disclosure 3.37 (1.42) 0.53 to 6.22 2.98 (1.53) 0.08 to 6.04 1.72 208 0.086
Confidence to challenge stigma 3.14 (1.03) 1.08 to 5.20 2.90 (0.95) 1.01 to 4.80 1.65 229 0.100
RIBS 4.46 (0.71) 3.03 to 5.88 4.55 (0.64) 3.26 to 5.83 0.82 175 0.412

RIBS, Reported and Intended Behaviour Scale.

a. Participants who had experienced contact were compared with participants who had not: fluctuations in the numbers and degrees of freedom throughout the analyses arise
because many participants did not complete all the measures.

Quality and quantity of contact In terms of overall effects on the target population, the mass
Using a single index of contact we found that contact predicted media component of the social marketing campaign seemed to
more positive attitude change (r = 0.33, P50.01) and greater be most effective at influencing intended behaviour. Several items
confidence to challenge mental health stigma (r = 0.38, P50.01). indicated pre–post improvements over several bursts; however, the
Results did not reach conventional levels of significance for RIBS ‘live with’ item was the only one that showed significant
contact predicting willingness to talk about one’s own mental longitudinal improvements among the total target population that
health problems (r = 0.20, P = 0.10) and failed to predict reported were sustained over the entire campaign period. A low baseline
intended behaviours (r = 0.06, P = 0.64). In our mediation model agreement with the item might have allowed for more substantial
(Fig. 5) the indirect effect of contact on confidence to challenge growth over time compared with other items. For instance,
stigma through attitudes was not zero, according to a 90% bias- agreement with other domains (e.g. ‘continue a relationship with’)
corrected bootstrap confidence interval based on 5000 bootstrap may have shown less change owing to a ceiling effect. Agreeing to
samples (0.007 to 0.125, with a point estimate of 0.053). The paths live with someone with a mental health problem, however, is also a
from contact to attitudes (a = 0.13, P = 0.003) and attitudes to highly active and personal behaviour which would suggest that
confidence to challenge stigma controlling for contact (b = 0.41, change would be difficult to achieve. It is possible that the change
P = 0.07) were also not zero. The direct path from contact to associated with this item was influenced by the campaign’s focus
confidence to challenge stigma was significant (c = 0.18, P = 0.02) on behaviour change and emphasis on involvement with the
and the product of a, b and c was positive (0.1360.4160.18 = public in ‘calls to action’. On average, knowledge about psycho-
0.010) indicating complementary mediation.27 therapy’s effectiveness improved from pre- to post-campaign
burst, yet over the study’s entire length the same knowledge
decreased. We could speculate that this pattern of transitory
Discussion improvement plus long-term deterioration is consistent with
TTC’s short-term effectiveness. However, the positive effects may
The evaluation of the Time to Change social marketing not have outweighed larger negative trends of societal attitudes,
campaign provides support for modest but positive and possibly shaped by other forces such as the worsening economic
significant improvements associated with the campaign, especially climate during the past years. If supported by other findings, this
in relation to intended behaviour. Although there was no pattern calls for more intense and prolonged interventions to
consistent improvement in knowledge or attitudes at the whole achieve long-term improvements.
population level, awareness of the campaign was consistently Time to Change is the first anti-stigma programme to include
associated with better knowledge, attitudes and intended an explicit target to change behaviour. This is in contrast to
behaviour. This was true when controlling for potential previous campaigns, which focused more on attitude change
confounders such as knowing someone with a mental health and improved awareness about mental health problems.30 The
problem, which in addition to being associated with better more recent focus on behaviour change may be in response to
outcomes might have made the campaign more salient. research which suggests that greater awareness of mental illness
Additionally, the association between positive intergroup contact, does not necessarily translate to improved attitudes and
achieved through TTC social contact events, and improved behaviours towards people with mental illness. For instance,
attitudes and willingness to challenge stigma and discrimination recent longitudinal reviews have demonstrated an increase in
suggests that social contact can be used by anti-stigma mental health literacy alongside a stable or increasing trend for
programmes to reduce stigma and discrimination against people social distance from people with major depression or schizo-
with mental health problems. phrenia.31–33 Therefore, the decreased desire for social distance
alongside unchanged knowledge levels during the TTC campaign
Changed is noteworthy and supports findings that improvements in
attitudes knowledge may not be necessary or sufficient to ensure behaviour
7

change.
Campaign awareness and social contact were the most
consistent positive predictors of better knowledge, attitudes and
intended behaviour towards people with mental illness.
6

Contact 7 Confidence to Incorporating inverse propensity weighting into the regression

challenge stigma models slightly attenuated the effects of campaign awareness;
however, the association between campaign awareness and
Fig. 5 Mediational model of the role of attitudes in explaining
knowledge, attitudes and behaviour remained significant.
the effects of contact on confidence to challenge stigma. Although both factors demonstrated consistent positive
associations, social contact had the greatest influence on mental

s85
Evans-Lacko et al

health-related knowledge, attitudes and behaviour and continued campaign awareness on knowledge, attitude and behaviour
to improve as the level of contact increased. We know from a large outcomes. Moreover, pre–post improvements around each burst
body of research that social contact is one of the most effective of activity suggest that changes can be attributed to the campaign.
strategies for improving intergroup relations,19,20,34,35 and benefits There were also methodological limitations associated with the
from the social contact events were likely to augment the effects of evaluation of the social contact events, including low response
the campaign. Calls to action and engagement of the public, for rate and missing data. Although tens of thousands of people
instance by social contact events, might work synergistically with attended social contact events, only a few dozen people had the
mass media to reduce stigma and discrimination against people task of asking attendees to complete a questionnaire. Another
with mental health problems. There is a body of evidence that methodological limitation is the absence of a follow-up and
interventions that contain personal information about individuals pre-intervention measure. A pre-intervention measure would have
with mental health problems, and give participants the opportunity allowed us to control for attitudes before the intervention and
to have a discussion while evoking empathy, are more likely to follow-up data would have allowed us to determine sustained
succeed.36 A strength of the TTC social contact events is that they change over time.
not only facilitated social contact but also provided educational Although our measure of intended behaviour does not capture
resources on mental health in the form of leaflets. It is likely that actual behaviour, the RIBS incorporates domains that are
combining educational information with a social contact inter- significant to the personal lives of people with mental health
vention might lead to greater reductions in mental health stigma problems and assesses experiences that are common among the
than education alone,37 and that engaging the public through general public. Including a wide range of measures that captured
events may promote changes in behaviour such as challenging the domains of knowledge, attitudes and behaviour was a strength
stigma and discrimination. as it allowed for a multifaceted assessment of stigma.4,39 Moreover,
Previous research has shown that anxiety mediates the these findings are significant as other research suggests that public
relationship between contact and prejudice,25,26 In this study attitudes and behaviour have a clear association with the views of
we attempted to explicate the mechanism that underlies the people with mental illness regarding their illness, expectations of
relationship between contact and confidence to challenge stigma discrimination and self-efficacy,40 in addition to facilitating
by using attitudes as a mediator variable. There have been several help-seeking and disclosure among the public.41,42 Nevertheless,
studies that have found anxiety to be a predictor of attitudes,25,26 further efforts are needed to inform changes at service user level
and also associated with motivation to respond without in reported stigma and discrimination as a response to anti-stigma
prejudice,38 therefore attitudes are a relevant alternative mediator campaigns. Although the campaign messages did not focus on one
variable to anxiety. Our study found that attitude change specific illness, more information about the influence of the
mediated the relationship between contact and confidence to campaign on knowledge, attitudes and behaviour in relation to
challenge stigma and discrimination. This is intuitive, because specific mental illnesses could inform whether the campaign was
for contact to potentially affect behaviours, attitudes need to be more or less effective in reducing stigma about certain types of
changed first. mental illnesses.43 The second set of MAKS items showed
improvement in knowledge of mental illness conditions.
Responses suggested that over time, the public was slightly less
Strengths and limitations of the study likely to consider non-psychiatric conditions such as grief or stress
To our knowledge this is the first evaluation of a national anti- to be mental illnesses.44 To keep the survey brief, however, in other
stigma social marketing campaign concurrently examining items we enquired only about mental health problems generally.
associated trends in public knowledge, attitudes and intended Finally, although we oversampled BME populations at each
behaviour in relation to mental illness. The evaluation involved time point, sample sizes among some BME subgroups were small.
careful definition of the method of delivery, communication The evaluation suggests that the campaign reached diverse groups
messages and target groups in relation to impact. Although this with higher campaign awareness among BME groups in four of
study contributes new and important information that can inform the six bursts. Interestingly, although BME respondents tended
the planning of future anti-stigma social marketing campaigns, to have greater campaign awareness, they also tended to respond
there are limitations that should be considered. Although the more negatively to the attitude and intended behaviour questions
sampling methods ensured equality of the target characteristics compared with White respondents. Because experiences and
(gender, age, socioeconomic group and geographic region) across perceptions of discrimination may vary by ethnic group or
time points for individuals completing the online survey, different community, it is important to understand the influence of the
individuals were interviewed at each time point. This diminishes campaign on subgroups.45,46
the potential of an effect resulting from repeating the interview;
however, we cannot be certain that differences in attitudes were
not due to sampling characteristics. Our assessment of campaign Implications
awareness included a detailed questioning process to assess Over the short term the social marketing component of the TTC
prompted and unprompted campaign awareness for each type campaign demonstrated important population-level gains in
of media, but we could only assess reported campaign awareness intended behaviour with respect to living with someone with a
and not actual awareness. Because we did not include a control mental illness. Although the trends associated with knowledge
group in our evaluation we cannot be certain what would have and attitudes were mixed, campaign awareness was associated with
happened without any campaign activity. It would be difficult to better knowledge, attitudes and intended behaviour. It is
include an adequate control at the country level owing to important to note that this impact was possible and sustained
differences in sociopolitical context; however, performing surveys without positive antecedent changes in public knowledge or
immediately before and after campaign activity and including a attitudes, and was achieved despite the developing economic
detailed assessment of campaign awareness allows us to better downturn and previous evidence that such public attitudes in
attribute changes to campaign activity. Additionally, incorporation England were deteriorating before the start of TTC.7 It is likely
of inverse probability weighting techniques in the regression that better knowledge and attitudes provide a more supportive
models provided rigour when estimating the causal effect of environment associated with less stigmatising behaviours, and

s86
 Influence of social marketing interventions

campaigns should incorporate a multifaceted approach towards 4 National Institute for Health and Clinical Excellence. Behaviour Change at
Population, Community and Individual Levels. Public Health Guidance PH6.
reducing stigma and discrimination. It is important to identify NICE, 2007 (http://www.nice.org.uk/PH006).
the messages, delivery and context when considering these
5 Evans-Lacko S, Little K, Meltzer H, Rose D, Rhydderch D, Henderson C, et al.
improvements as they may not generalise to all anti-stigma social Development and psychometric properties of the Mental Health Knowledge
marketing campaigns. Therefore, it is important to consider Schedule. Can J Psychiatry 2010; 55: 440–8.
improvements in relation to a specific message or activity.47,48 6 Rusch N, Evans-Lacko S, Thornicroft G. What is a mental illness? Public views
Future research should examine mechanisms through which and their effects on attitudes and disclosure. Aust N Z J Psychiatry 2012; 46:
641–50.
social contact could be facilitated by social marketing, in addition
to improving understanding of how changes in public knowledge, 7 Mehta N, Kassam A, Leese M, Butler G, Thornicroft G. Public attitudes
towards people with mental illness in England and Scotland, 1994–2003.
attitudes and behaviour among the general public influence Br J Psychiatry 2009; 194: 278–84.
perceptions and experiences of stigma and discrimination of
8 Taylor SM, Dear MJ. Scaling community attitudes toward the mentally ill.
people using mental health services, and how far, for example, Schizophr Bull 1981; 7: 225–40.
filmed personal disclosure by people with mental health problems 9 Cohen J, Struening EL. Opinions about mental illness in the personnel of two
has a positive impact.49 The mass media component and the large mental hospitals. J Abnorm Soc Psychol 1962; 64: 349–60.
associated mass-participation social contact events probably 10 Evans-Lacko S, Henderson C, Thornicroft G. Public knowledge, attitudes
worked together; the social contact events are likely to have and behaviour regarding people with mental illness in England 2009–2012.
contributed to the effectiveness of the wider TTC programme, Br J Psychiatry 2013; 202 (suppl 55): s51–7.

and the associations with positive social contact suggest that they 11 Vaughan G, Hansen C. ’Like Minds, Like Mine’: a New Zealand project to
counter the stigma and discrimination associated with mental illness.
should be an integral part of anti-stigma campaigns.37 Further Australas Psychiatry 2004; 12: 113–7.
research is needed to understand how to optimise resources and
12 Jorm AF, Christensen H, Griffiths KM. Changes in depression awareness and
create synergies across multiple interventions and also to under- attitudes in Australia: the impact of beyondblue: the national depression
stand how initiatives might be integrated across communities initiative. Aust N Z J Psychiatry 2006; 40: 42–6.
locally and nationally to lead to the greatest population impact. 13 Angermeyer MC, Dietrich S. Public beliefs about and attitudes towards
Finally, maintenance of these changes should be monitored over people with mental illness: a review of population studies. Acta Psychiatr
Scand 2006; 113: 163–79.
time as it is likely that long-term investment is needed to achieve
population changes.50 14 Corrigan PW, Rowan D, Green A, Lundin R, River P, Uphoff-Wasowski K, et al.
Challenging two mental illness stigmas: personal responsibility and
dangerousness. Schizophr Bull 2002; 28: 293–309.
Sara Evans-Lacko, PhD, Estelle Malcolm, MSc, Health Service and Population
15 Thompson AH, Stuart H, Bland RC, Arboleda-Florez J, Warner R, Dickson RA,
Research Department, King’s College London, Institute of Psychiatry, London; Keon
West, DPhil, Department of Psychology, University of Roehampton, London; Diana et al. Attitudes about schizophrenia from the pilot site of the WPA worldwide
Rose, PhD, Jillian London, MSc, Health Service and Population Research campaign against the stigma of schizophrenia. Soc Psychiatry Psychiatr
Department, Institute of Psychiatry, London, UK; Nicolas Rüsch, MD. Health Service Epidemiol 2002; 37: 475–82.
and Population Research Department, Institute of Psychiatry, London, UK and
16 Evans-Lacko S, Rose D, Little K, Flach C, Rhydderch D, Henderson C, et al.
Psychiatric University Hospital Zürich, Switzerland; Kirsty Little, PhD, Claire
Henderson, PhD, Graham Thornicroft, PhD, Health Service and Population Development and psychometric properties of the reported and intended
Research Department, Institute of Psychiatry, London, UK behaviour scale (RIBS): a stigma-related behaviour measure. Epidemiol
Psychiatr Sci 2011; 20: 263–71.
Correspondence: Dr Claire Henderson, Health Service and Population Research
Department, Institute of Psychiatry, PO Box 29, De Crespigny Park, London
17 Link BG, Yang LH, Phelan JC, Collins PY. Measuring mental illness stigma.
SE5 8AF, UK. Email: [email protected] Schizophr Bull 2004; 30: 511–41.
18 Hamilton S, Pinfold V, Rose D, Henderson C, Lewis-Holmes E, Flach C, et al.
The effect of disclosure of mental illness by interviewers on reports of
discrimination experienced by service users: a randomized study. Int Rev
Psychiatry 2011; 23: 47–54.
Funding
19 Allport G. The Nature of Prejudice. Addison, 1954.
The study was funded by the Big Lottery Fund and Comic Relief. G.T. is funded in relation 20 Pettigrew TF, Tropp LR. A meta-analytic test of intergroup contact theory.
to a National Institute for Health Research (NIHR) Applied Programme grant awarded to the J Pers Soc Psychol 2006; 90: 751–83.
South London and Maudsley National Health Service (NHS) Foundation Trust. G.T. and D.R.
are funded in relation to the NIHR Specialist Mental Health Biomedical Research Centre at 21 Holmes EP, Corrigan PW, Williams P, Canar J, Kubiak MA. Changing attitudes
the Institute of Psychiatry, King’s College London and the South London and Maudsley NHS about schizophrenia. Schizophr Bull 1999; 25: 447–56.
Foundation Trust. C.H. and S.E.L. are supported by a grant to Time To Change from Big
Lottery and Comic Relief. C.H. is funded by a NIHR Applied Programme grant awarded
22 Curtis LH, Hammill BG, Eisenstein EL, Kramer JM, Anstrom KJ. Using inverse
to the South London and Maudsley NHS Foundation Trust and a grant from Guy’s and St probability-weighted estimators in comparative effectiveness analyses with
Thomas’ Charity.## observational databases. Med Care 2007; 45 (suppl 2): s103–7.
23 Hirano K, Imbens G. Estimation of causal effects using propensity score
weighting: an application to data on right heart catheterization. Health Serv
Acknowledgements Outcomes Res Methodol 2001; 2: 259–78.
24 Rubin D. Using propensity scores to help design observational studies:
We are grateful for the comments and feedback provided by our statistical consultants, application to the tobacco litigation. Health Serv Outcomes Res Methodol
Clare Flach and Morven Leese, and to Bruce Link for his comments on an earlier draft 2001; 2: 169–88.
of this article. We thank Sue Baker, Maggie Gibbons, Paul Farmer, Paul Corry, Katherine
Crawshaw and Sarah Cohen for their collaboration on the evaluation. We would also like 25 Voci A, Hewstone M. Intergroup contact and prejudice toward immigrants in
to thank Consumer Insight for their assistance with data collection. Italy: the mediational role of anxiety and the moderational role of group
salience. Group Process Intergroup Relat 2003; 6: 37–54.
26 West K, Hewstone M. Culture and contact in the promotion and reduction of
References anti-gay prejudice: evidence from Jamaica and Britain. J Homosex 2012; 59:
44–66.

1 Corrigan PW. Where is the evidence supporting public service 27 Zhao X, Lynch JG, Chen Q. Reconsidering Baron and Kenny: myths and truths
announcements to eliminate mental illness stigma? Psychiatr Serv 2012; 63: about mediation analysis. J Consumer Res 2010; 37: 197–206.
79–82. 28 Baron RM, Kenny DA. The moderator mediator variable distinction in social
2 Henderson C, Thornicroft G. Stigma and discrimination in mental illness: Time psychological research – conceptual, strategic, and statistical considerations.
J Pers Soc Psychol 1986; 51: 1173–82.
to Change. Lancet 2009; 373: 1928–30.
29 Fritz MS, MacKinnon DP. Required sample size to detect the mediated effect.
3 Henderson C, Evans-Lacko S, Flach C, Thornicroft G. Responses to mental
Psychol Sci 2007; 18: 233.
health stigma questions: the importance of social desirability and data
collection method. Can J Psychiatry 2012; 57: 152–60. 30 Sartorius N. Short-lived campaigns are not enough. Nature 2010; 468: 163–5.

s87
Evans-Lacko et al

31 Angermeyer MC, Holzinger A, Matschinger H. Mental health literacy and 41 Schomerus G, Matschinger H, Angermeyer MC. The stigma of psychiatric
attitude towards people with mental illness: a trend analysis based on treatment and help-seeking intentions for depression. Eur Arch Psychiatry
population surveys in the eastern part of Germany. Eur Psychiatry 2009; 24: Clin Neurosci 2009; 259: 298–306.
225–32. 42 Rusch N, Evans-Lacko SE, Henderson C, Flach C, Thornicroft G. Knowledge
32 Pescosolido BA, Martin JK, Long JS, Medina TR, Phelan JC, Link BG. ‘A disease and attitudes as predictors of intentions to seek help for and disclose a
like any other’? A decade of change in public reactions to schizophrenia, mental illness. Psychiatr Serv 2011; 62: 675–8.
depression, and alcohol dependence. Am J Psychiatry 2010; 167: 1321–30. 43 West K, Hewstone M, Holmes EA. Rethinking ’mental health stigma’. Eur J
33 Schomerus G, Schwahn C, Holzinger A, Corrigan PW, Grabe HJ, Carta MG, et Public Health 2010; 20: 131–2.
al. Evolution of public attitudes about mental illness: a systematic review and 44 Rusch N, Evans-Lacko S, Thornicroft G. What is a mental illness? Public views
meta-analysis. Acta Psychiatr Scand 2012; 125: 440–52. and their effects on attitudes and disclosure. Aust N Z J Psychiatry 2012; 46:
34 Corrigan PW, River LP, Lundin RK, Penn DL, Uphoff-Wasowski K, Campion J, 641–50.
et al. Three strategies for changing attributions about severe mental illness. 45 Knifton L, Gervais M, Newbigging K, Mirza N, Quinn N, Wilson N, et al.
Schizophr Bull 2001; 27: 187–95. Community conversation: addressing mental health stigma with ethnic
minority communities. Soc Psychiatry Psychiatr Epidemiol 2010; 45: 497–504.
35 Corrigan PW, Morris S, Michaels P, Rafacz J, Rusch N. Challenging the public
stigma of mental illness: a meta-analysis of outcome studies. Psychiatr Serv 46 Shefer G, Rose D, Nellums L, Thornicroft G, Henderson C, Evans-Lacko S.
2012; 63: 963–73. ’Our community is the worst’: the influence of cultural beliefs on stigma,
relationships with family, and help-seeking in three ethnic communities
36 Mann CE, Himelein MJ. Putting the person back into psychopathology: an
in London. Int J Soc Psychiatry 2012; Jun 8: epub ahead of print
intervention to reduce mental illness stigma in the classroom. Soc Psychiatry
(doi: 10.1177/0020764012443759).
Psychiatr Epidemiol 2008; 43: 545–51.
47 Clement S, Lassman F, Barley E, Evans-Lacko S, Williams P, Pagdin R, et al.
37 Chan JY, Mak WW, Law LS. Combining education and video-based contact to Mass media interventions to reduce mental health-related stigma (Protocol).
reduce stigma of mental illness: ‘The Same or Not the Same’ anti-stigma Cochrane Database Syst Rev 2011; issue 12: CD009453.
program for secondary schools in Hong Kong. Soc Sci Med 2009; 68: 1521–6.
48 Clement S, Jarrett M, Henderson C, Thornicroft G. Messages to use in
38 Plant EA, Devine PG. Internal and external motivation to respond without population-level campaigns to reduce mental health-related stigma:
prejudice. J Pers Soc Psychol 1998; 75: 811. consensus development study. Epidemiol Psichiatr Soc 2010; 19: 72–9.
39 Link BG, Phelan JC. Conceptualizing stigma. Annu Rev Sociol 2001; 27: 49 Clement S, van Nieuwenhuizen A, Kassam A, Flach C, Lazarus A, de Castro
363–85. M, et al. Filmed v. live social contact interventions to reduce stigma:
40 Evans-Lacko S, Brohan E, Mojtabai R, Thornicroft G. Association between randomised controlled trial. Br J Psychiatry 2012; 201: 57–64.
public views of mental illness and self-stigma among individuals with mental 50 Wakefield MA, Loken B, Hornik RC. Use of mass media campaigns to change
illness in 14 European countries. Psychol Med 2012; 16: 1–13. health behaviour. Lancet 2010; 376: 1261–71.

s88
Influence of Time to Change's social marketing interventions on
stigma in England 2009-2011
Sara Evans-Lacko, Estelle Malcolm, Keon West, Diana Rose, Jillian London, Nicolas Rüsch, Kirsty Little,
Claire Henderson and Graham Thornicroft
BJP 2013, 202:s77-s88.
Access the most recent version at DOI: 10.1192/bjp.bp.113.126672

References This article cites 46 articles, 13 of which you can access for free at:
http://bjp.rcpsych.org/content/202/s55/s77#BIBL
Reprints/ To obtain reprints or permission to reproduce material from this paper, please
permissions write to [email protected]

You can respond /letters/submit/bjprcpsych;202/s55/s77

to this article at
Downloaded http://bjp.rcpsych.org/ on April 3, 2017
from Published by The Royal College of Psychiatrists

To subscribe to The British Journal of Psychiatry go to:

http://bjp.rcpsych.org/site/subscriptions/