Evaluation of 'see me' - the National Scottish Campaign Against the Stigma and Discrimination Associated with Mental Ill-Health

CHAPTER TEN ASSESSING EFFECTIVENESS

Introduction

10.1 Drawing from across the range of data sources including documentary material, surveys, interviews and focus groups, this chapter focuses on the evaluation's second aim of determining the extent to which 'see me' has met its own strategic objectives (Box 10.1) and identifying the barriers and facilitating factors.

Box 10.1 'see me''s strategic objectives

1. To tackle stigma and discrimination by raising public awareness of how both affect individuals with mental health problems, and by improving public understanding of mental health

2. To challenge individual incidents of stigma and discrimination

3. To involve people in anti-stigma activities across Scotland at national and local levels and across sectors and communities of interest

4. To ensure that the voices and experiences of people with mental health problems and their carers are heard

5. To promote a culture of learning and evaluation through all its work, so that effectiveness can be demonstrated and lessons shared.

Strategic objective 1 - Raising public awareness

Quantitative indicators

Public attitudes

10.2 The evaluation did not include quantitative surveys to assess the effectiveness of 'see me'. Data from the 'Well? What do you think?' survey (Braunholtz et al, 2007) do however, enable a comparison of attitudes to mental health problems over the period immediately prior to the launch of the campaign and subsequently in 2004 and 2006.

10.3 Although the published data do not include analyses of statistical significance they are suggestive of some degree of attitudinal change ( Annex 6). This is most notable in relation to perceptions of dangerousness where there is a substantial decrease over the period in the proportions agreeing that "people with mental health problems are often dangerous". But what is also illustrated is the instability in the patterns; changes between 2002 and 2004 are not necessarily sustained by 2006. Agreement with the view that the public should be better protected from people with mental health problems, for example, decreases then rises. A number of different interpretations have been proposed for this apparent instability, including, for example, in relation to this specific item, the influence of negative media interest in the issue of secure care at the time that data for the 2006 survey was being collected.

10.4 The 'Well? What do you think?' survey also indicates changes in the patterns of perceived stigma and discrimination by people with direct experience of mental health problems. Over the period 2002 to 2006, the proportions of people who indicated that they had not experienced any difficulties from others because of their mental health problems rose from 68% in 2002 to 75% in 2006 (with a slight dip to 64% in 2004). Among those who had experienced difficulties this was most frequently in relation to participation in social events. In 2002, 12% of the sub-sample of respondents felt they had been discouraged by others from taking part in a social activity because they had a mental health problem, this rises to 15% in 2004, but decreases to 11% in 2006.

10.5 'see me' commissioned a number of attitude surveys that were run immediately prior to and post the general public campaign strand launches (see Annex 7 for list of 'see me' commissioned surveys). Street surveys of 525 randomly recruited adults were run in December 2002, immediately after the October 2002 launch, in Aberdeen, Stirling and Edinburgh and again in Aberdeen and Edinburgh in February 2003. These were augmented by telephone Omnibus surveys of over 1,000 people undertaken in March 2003, and also immediately prior to and post the second general public campaign strand launch in October/November 2003. The data from the street survey and Omnibus surveys are summarised in Annex 8.

10.6 The data suggest some positive changes in expressed attitudes between December 2002 and November 2003, for example the decrease in the numbers of people who would not want others to know if they had a mental health problem, and in the proportions believing people with a mental health problem are often dangerous. There are also increases in the proportions believing that the majority of people with mental health problems recover and that people with mental health problems should have the same rights as other people. Again the pattern over this short time period is not consistent, there is, for example, a marginal increase in negative attitudes between campaigns, and some improvement immediately post campaign, but also some attitudes changing outwith any campaign activity.

Campaign awareness

10.7 The 'Well? What do you think?' surveys have tracked public awareness of the different initiatives running under the National Programme over the years 2004 and 2006 ( Annex 9). Although different campaigns have different levels of funding, different aims and different histories, there is a value in comparing awareness of the different initiatives as a measure of brand recognition, albeit that people may not necessarily know what the brand is advertising. In answer to the question 'There have been a number of campaigns, initiatives and promotional activity regarding mental health in Scotland. Have you heard of any of the following or not?' the survey responses suggest that over this short time period campaign awareness of 'see me' has increased from 34% to 37%, that is, to over one-third of the adult population. Over this same period, however, awareness of Choose Life, which is not perceived as a campaigning body, has also increased from 26% to 32%, while that of HeadsUpScotland was as high as 19%.

10.8 What the 2006 survey also found was that across the different initiatives, awareness is lower among people with no personal experience of mental health problems (either directly or through someone they know). In relation to 'see me', awareness falls from 43% of those with direct experience of a mental health problem, to 21% among people with no experience. The comparable figures for Choose Life are 34% and 23%. In effect, awareness of the name 'see me' appears to be marginally lower among people with no experience of mental health problems than Choose Life.

10.9 'see me''s own assessment of the reach and recall of its general public campaign strand is reflected in the findings from the street surveys and Omnibus telephone surveys, described above. The findings from the Omnibus surveys are summarised in Annex 10. The data indicate that spontaneous recall of hearing or seeing advertising on stigma and discrimination toward people with mental health problems was 20% in December 2002, following the campaign launch in the October, peaked in March 2003 and rose to 28% following the launch of the second general public campaign strand in October 2003. Of those surveyed in December 2002, 16% could recall seeing or hearing advertising of this nature if prompted, this rose to 20% following the second launch.

Measuring the impact of other campaign strands

10.10 Although the Employment and Workplace campaign strand, launched in July 2004, underwent a comprehensive pre-campaign development process (see Chapter 6) it has not been subject to post-campaign evaluation. This is because the focus has been on building a 'commitment movement' of local and national companies, to whom 'see me' would then go back and suggest joint action which could then be evaluated. There is therefore currently no quantitative data, beyond requests for campaign materials and media 'spots', to indicate the impact of this campaign strand.

10.11 Evaluation of the young people's campaign included a pre-launch 'tracking survey' of 448 children in two schools in Orkney and Dunfermline, followed up by a post launch survey completed by 406 young people in schools in Orkney, Clydebank and Haddington in April/May 2005 (Citigate Smarts, 2005a; 2005b). It is understood that schools from these areas were selected to ensure geographical spread and an urban/rural mix. Although the schools in Orkney comprised 70% of the pre-sample of 448 young people, and only 10% of the follow up sample of 406, there is no discussion of whether and how this unequal distribution by geographical area may have impacted on the overall findings.

10.12 The tracking survey was followed up in September 2005 by four focus groups: two in one school in Clydebank and two in a school in Haddington. These groups involved a total of 44 participants, including 20 aged 12-13 years and 24 between the ages of 15 and 17.

10.13 To provide an indication of the level of campaign awareness and self-reported impacts on attitudes prior to and after the launch of the young people's campaign strand the following focuses on the two tracker surveys.

Campaign awareness

10.14 The follow up report on the two surveys prepared by Citigate Smarts (2005b) suggests that:

Among the follow-up sample (n=406), prompted recall of the two cartoon characters used in the young people's campaign was around 47%. Of the total sample, 189 (43%) recalled seeing a TV advertisement featuring the cartoon characters. A third of the follow-up sample had not seen the advert
Of the 255 young people (63% of the total sample) who responded to the question "what do you think the adverts are about?", 83 suggested that they were about bullying, and 55 that they were related to mental health
Of the 189 who had seen the advertisements, 10% had talked about them with friends, teachers or family. Approximately 11 young people felt that the advertising had had an impact either on themselves or their friends, including by increasing awareness of mental health.

10.15 The data reproduced do suggest that, approximately three to four months after the launch of the campaign strand, around half the young people sampled were aware of the advertisements, suggesting a sizeable reach and recall. Awareness of the focus of the campaign is perhaps more diffuse, but some were picking up the specific mental health message, including a small number who had felt moved to talk about the campaign with people they knew. It is not known whether these young people were already in some way sensitised to the issues.

Young people's knowledge about mental health problems

10.16 Pre- and post-campaign the young people were asked to indicate from a list the diagnoses/disabilities those that they thought were mental health problems. Table A11.1 in Annex 11 indicates the responses over time.

10.17 What the data suggest is an increase in awareness of anorexia (targeted in the 'Cloud Girl' campaign), stress and 'manic depression' as mental health problems. Data produced by Citigate Smarts indicate that this increase is greatest amongst those who recalled the advertising. The data also suggest marginal reductions in the number of young people who considered Autism, Multiple Sclerosis, Alzheimer's Disease, Parkinson's Disease and Dyslexia to be mental health problems. This indicates an increasing awareness of both what is and what is not a mental health problem. Conversely, however, fewer were identifying schizophrenia as a mental health problem, while marginally more were including ADHD in this category.

10.18 The data suggest positive changes in attitude, but again, no statistical analyses have been done to determine their statistical significance. Given that anorexia and self-harm were the main targets of the campaign, it is also not clear how the advertisements on their own could have impacted on knowledge of the other diagnoses/disabilities listed. This also needs further consideration given that over half of the follow-up sample could not recall seeing the advertisements. Again, the impact of other initiatives, and possibly even activities within the schools to contextualise the surveys, may have made some contribution to the changes.

Young people's attitudes

10.19 The tracking surveys also included a series of attitude questions to identify possible changes pre- and post-campaign. These included both attitudes towards adults with mental health problems and those towards young people. Table A11.2 in Annex 11 summarises the data comparing the pre- and post-surveys. This again draws on the reports prepared by Citigate Smarts. The follow-up report only includes analyses of attitudes towards young people with a mental health problem.

10.20 The data suggest very little change in attitudes overall, although again there are no assessments of statistical significance. Insofar as there has been change, it is not in any consistent direction. Along some dimensions, attitudes appear to have become more 'positive', most noticeably in relation to the perceived attitudes of other young people towards those with mental health problems - a focus for the young people's campaign strand. Conversely, marginally more believed that young people who hear voices should be locked up.

10.21 A further set of questions in both the pre- and post-campaign surveys asks the young people to indicate how they would feel and whether they would know what to do if a friend was feeling down all the time, or deliberately cut themselves (self-harm being one of the campaign strand targets), or was hearing voices. The data presented in the report suggest positive changes overall across the three different problems in terms of fears for themselves or for their friends or in the proportions feeling they would know what to do to help their friend. The commentary prepared by Citigate Smarts suggests that post-campaign, those who could recall seeing the advertisements were more likely to feel that they would know how to help their friend than those who had not been exposed. The data from the commentary and pre-campaign report are summarised in Table A11.3 in Annex 11.

10.22 The material made available therefore suggests that young people who had been exposed to the campaign felt they were more confident about knowing what to do if they had a friend who told them they were experiencing certain difficulties. What is perhaps difficult to account for, however, are the decreased levels of confidence (compared with the overall pre-campaign figures) among those who had not seen the campaign.

10.23 What is missing from the follow up study is an analysis by gender or age (this may have been undertaken, but was not made available in the report). This takes on significance in the light of a finding from the pre-campaign survey that the most discriminatory attitudes were amongst the older age groups, who were also identified as the most knowledgeable. Further, it was found that boys tended to have more negative attitudes than girls. Clearly, if this is the case it has important implications for further targeting and, potentially, even consideration of the assumption that knowledge per se impacts on attitudes.

10.24 Overall the data from the children and young people's tracking surveys suggest that the campaign reached about half of those surveyed, and had some effect in terms of attitudes and perceived confidence in dealing with a friend experiencing mental health difficulties.

The repertoire effect

10.25 Clearly the national and specially commissioned surveys do indicate some shifts in mental health awareness and in expressed attitudes, though the comparatively short time periods covered at this early stage make it difficult to interpret some of the emerging trends. While not wishing to undermine the contribution of 'see me', some caution should, however, be exercised before attributing responsibility for effecting attitudinal change (in either direction) solely or primarily to the campaign, given the repertoire effect of a number of other initiatives coming on stream over this time period. As discussed in Chapter 3, 'see me' is just one of a number of policy and legislative initiatives, including the Mental Health (Care and Treatment) (Scotland) Act 2003, the Disability Discrimination Acts of 1995 and 2005, health improvement policies as well as the initiatives developed under the umbrella of the National Programme. A number of public sector, but non-mental health, agencies described how the Mental Health (Care and Treatment) Scotland Act 2003, Scotland's Mental Health First Aid, and also the 'Delivering for Mental Health' plan (launched in December 2006), had acted as major triggers to addressing mental health awareness and mental health related stigma and discrimination. Representatives of the National Programme delivery vehicles commented that, although 'see me' was leading in the field of activity relating to the stigma associated with mental health problems, other activities, including their own, were making a contribution in different ways. This is perhaps given further corroboration by the patterns of awareness of different mental health related campaigns. As indicated above, by 2006, almost as many people were aware of the name Choose Life, for example, as they were of 'see me'.

10.26 Rather than taking away from what 'see me' has achieved, this does seem to reinforce the value of having different initiatives working at different levels and with different emphases to collectively affect perceptions of and attitudes towards mental health and mental health problems.

Qualitative findings from the current evaluation

10.27 To provide added support to and possible explanations for the quantitative data, participants in focus groups, surveys and interviews across the three phases of the evaluation were asked about their awareness of the campaign and their personal perceptions of whether it had had an impact. Respondents included those directly involved in the mental health system (including health and social care), as well as people at one step removed i.e. working in regeneration, private industry/employment, anti-poverty, prison and police sectors.

10.28 Clearly, people were talking from their own perspectives, and in some respects their comments are 'anecdotal' drawing on their personal experience, rather than on research or evaluations undertaken within their fields. Further, the numbers involved from across and within sectors or organisations are small. This is not to dismiss the validity of these views, but to put them in context. While arguably not 'representative' nor 'evidence based' these experience-based views - whether positive, negative or neutral about the campaign - nonetheless draw attention to or raise important issues that require consideration.

10.29 What is also perhaps indicated is the need for more systematic evaluation of activities at 'local'/organisations/sector level aimed at addressing the stigma and discrimination experienced by people with mental health problems. As noted in Chapter 7, of the 28 activities described in the NHS Board area survey only 10 had been evaluated.

10.30 Unless otherwise stated, the views reported are those of individuals outwith those directly linked with 'see me' either operationally or managerially.

Campaign awareness

10.31 On the basis of personal experience, people from across the different sectors included in the evaluation indicated a personal awareness of the campaign, whether through their professional roles, or in their private capacities as members of the general public. People spoke positively of the television advertisements and posters, and the tone of the campaign, reflecting 'see me''s own aspirations not to alienate people by the use of a hectoring tone. People working with young people reflected back the generally positive comments of the young people who had seen the material. One respondent, outwith 'see me' made the point that when they put campaign materials out at conferences people look at and pick up materials rather than just walk past.

10.32 A consistent term used to describe the campaign was its "visibility", both in terms of the high profile quality images and in terms of contributing to putting mental health as an issue on people's "radar".

10.33 The campaign was perceived to be a combination of raising awareness, confronting myths about and "normalising" mental health problems in the sense of emphasising these as a common experience.

10.34 The targets were also felt to be well-chosen, particularly the focus on young people - less because of the issues of self-harm and eating disorder, which, from the perspective of several respondents, were perceived as quite narrow - but because it helped to raise awareness before attitudes hardened.

Perceived nature and direction of impact

10.35 In terms of perceived impact, one focus group of service users described, anecdotally, a possible negative effect describing how children in the playground "use the campaign as a way to slag people off, going around saying things like "see me, I'm a schizo". This, however, was the only indication of a negative impact. Other responses across the different data sources, suggest that people perceived the campaign as having a generally positive or 'neutral' impact, 'neutral' in the sense that the campaign was felt not to have reached certain groups. This 'neutral' perspective is discussed further below.

Perceived positive impacts

10.36 Although only about one-third of the 28 activities described in the NHS Board area survey were subject to evaluation, respondents described positive outcomes for 23. These included, raising the profile of 'see me' campaign messages, anticipated or increased awareness of mental health issues among local populations, changed attitudes towards mental health, an increased profile for local mental health initiatives and organisations and mental health benefits of users involved in activities.

10.37 As these examples from the NHS Board survey suggest, 'positive' impacts can be identified at individual, organisational / professional and systemic level.

Perceived individual level impacts

10.38 Individual level impacts include the experiences of media volunteers who not only felt they had gained personally from their role as volunteers (see Chapter 8), but were able to recount instances of people coming up to them after they had spoken to talk about their own experiences.

10.39 Other people, talking from an employment perspective, suggested that the apparent greater readiness to admit to stress as the reason for absence from work, rather than using 'backache', was a sign of greater openness, to which 'see me' was felt to have made a contribution.

Perceived organisational/professional impacts

10.40 Perhaps linking individual and professional level impacts, one professional felt that the materials had made him reflect on his own potentially stigmatising behaviours.

10.41 Representatives from different organisations or different professional groups, including those outwith the health and social care professions, perceived a change, to some extent, in the awareness of mental health issues among front line staff. Two organisations reflecting a housing/regeneration focus both independently felt there was a level of mental health awareness among staff that they had not seen before. While not attributing this cultural shift solely to 'see me' they did see it as a result of the wider policy environment of which 'see me' was a part.

10.42 As discussed in Chapter 7, for organisations and institutions outwith health and social care, bringing in 'see me' to support activities, both improved the profile of the companies as organisations who took the mental health and well-being of their staff seriously, but also helped to shift the culture, particularly in traditionally "macho" environments in which it can be difficult for people to admit they are having problems.

10.43 In the public sector, one respondent described the introduction of their mental health and well-being strategy as a way of ensuring what they described as more visible support for the 'see me' "philosophy".

10.44 A key area of professional practice where 'see me' was perceived to have had visible impact was in relation to media reporting. Consistently across the different participant groups (including users, carers, and representatives from the National Programme delivery vehicles and mental health or disability-related voluntary and statutory sectors), the view was that, compared with England, there had been a noticeable reduction in negative headlines and reporting.

Perceived systemic impacts

10.45 For both the public and private sector, the value of 'see me' was that it was something that could be used, rather than having to develop something themselves. What also emerges from across the different data sources is a perception of 'see me' not just as a resource, in terms of the 'hardware' of leaflets and posters and the 'software' of its perceived expertise, but its role as a "galvanizing force".

10.46 The campaign was seen as providing a catalyst and a focus for addressing stigma, giving activities a focus and legitimacy. In addition, members of the 'see me' management group felt that working together on the campaign had brought a greater understanding of each other's organisations. Two of the organisations represented had gone on to undertake joint work outwith the 'see me' context. One member of the management group also suggested that the campaign had had a "galvanizing" effect on the mental health community in Scotland. Together with the work of the National Programme, it was felt to have helped this community feel more "valued".

10.47 From a slightly different perspective, a voluntary organisation outwith the 'see me' management group felt that the campaign had also reflected and supported a shift in the mental health service user movement from a focus on mental health problems and specifically health care services, to a broader equalities agenda.

10.48 A third potential systemic impact, is the across sector learning. This is discussed further below but the scope for learning from 'see me' by other bodies addressing other sources of stigma and discrimination also suggests a wider impact beyond specifically mental health problem related activity.

"Yes, but…."

10.49 As already suggested the quantitative data from the national 'Well? What do you think?' surveys and those commissioned by 'see me' suggest that there have been positive changes in attitudes over the period 2002-2006. Further, the perception from respondents interviewed across the three phases of the evaluation was that 'see me' had been a force for good in raising public awareness of mental health problems. Nonetheless the comments and responses also raise a number of questions that, while not intended to undermine what has been achieved may suggest areas for consideration in future work to address the stigma and discrimination experienced by people with mental health problems.

A victim of its own success?

10.50 The quality of the campaign and the recognised expertise vested in 'see me' may have the unintended consequence of deferring responsibility for anti-stigma work to the campaign, rather than embedding it within agencies and organisations. This was touched upon both in the discussions with the National Programme delivery vehicles (see Chapter 7), but also by a respondent from an equalities agency who wanted to ensure that local bodies, such as GPs took on responsibility, and did not "pass the buck back to 'see me'". At the same time, the fact that there was an 'off the shelf' 'quality rated' campaign upon which non-specialist agencies could draw may also encourage take up.

10.51 A further issue is the need for continuity. As a number of respondents, both those directly associated with 'see me' and those outwith commented, awareness-raising campaigns have only a short shelf life, and without being sustained and "refreshed" any gains are lost. Further, that although it was a "job well done" it was not a case of a "job done"; the view was that the process of addressing stigma had begun but was not complete. A number of respondents felt that the initially high profile had, however, been weakened, a possible function of refocusing on supporting local level work, a tension discussed in Chapter 4.

Limits to reach?

10.52 A further issue raised by respondents was whether there are parts of the general population that 'see me' has been less successful in reaching. This had two dimensions: first the extent to which 'see me' had been able to reach beyond the environments of the willing or already sensitised, if not the already converted; second, whether the approach taken may unwittingly have systematically excluded some groups from the campaign and the campaign's messages.

10.53 Respondents who were personally aware of the campaign and prepared to talk about its impact nonetheless frequently added the caveat that they were not sure about the extent to which it had reached those who did not necessarily already have a degree of professional or personal awareness, including others within their own fields. A professional working in one not-for-profit agency commented, "I can see what they are trying to achieve as someone who works in the field, but I'm not sure if the general public would be that clued up about the messages they are trying to get across".

10.54 As already noted, and as the respondents commented, these were personal conjectures and did not draw on a systematic evidence base. The 'Well? What do you think?' surveys and 'see me''s own assessments of reach and recall following campaigns would seem to suggest some degree of incursion beyond the already sensitised. However, there were also comments that suggest that confidence in the reach of the campaign does need to be tempered.

10.55 First, as was revealed by the NHS Board area survey and workshops as well as the interviews with people from different organisations and agencies, local take-up, whether at an area-level or within agencies or organisations is variable, and is contingent on local factors, including product champions in a position to effect action. The lack of local co-ordinators with specific responsibility may be a contributory factor. But this also raises issues for both mainstreaming and sustainability of anti-stigma and discriminatory activity (see Chapter 11).

10.56 Second, in the key area of employment and employability, comments of a number of respondents suggest that the starting point in terms of effecting change was still very far back. It was suggested, for example, that although employers were increasingly responding to the employability agenda (within a context of labour shortages) this did not necessarily extend to the employment of people with experience of mental health problems. Similarly, it was suggested that there was scope for considering the barriers to the inclusion of people with mental health problems in collective bargaining structures.

10.57 The comments of the respondents from the two private companies interviewed as part of the evaluation suggest that, in some areas, there is a readiness and a willingness to demonstrate support for the campaign. In one of these companies, two suicides indirectly led the company to the campaign, via the Choose Life co-ordinator. In the second company, the distribution of the materials was in a context in which it was felt they already had good mental health policies in place. While giving visibility to 'see me' and to the organisation's support for the campaign's messages, in neither company was it suggested that systems or practices changed as a result of the campaign. This was either because systems were perceived to already be 'robust' or because "other things take priority".

10.58 While effecting change in attitudes and behaviours in the areas of employment/employability are not the responsibility of 'see me', given the campaign's own strategic objective to tackle "stigma and discrimination by raising public awareness of how both affect individuals with mental health problems, and by improving public understanding of mental health" the responses do suggest there is further scope for partnership working within key specific sectors to effect this objective, particularly in contexts where there is not already a degree of sensitisation to the issues. This issue is returned to below in Chapter 13.

10.59 The third dimension of reach relates to the way in which the population or populations have been segmented. To date the national campaign has been targeted at an undifferentiated 'general population', the 'workplace' and 'young people'. This was based on a strategic decision not to distinguish different groups within these broad categories. In 2003, for example, 'see me' documentary material refers to a decision not to focus specifically on black and minority ethnic communities, pending 'see me' finding out more about the specific ways in which mental ill-health and stigma were experienced by different BME communities.

10.60 In November 2004, 'see me' convened a roundtable event to support the campaign to "deliver the anti-stigma message to BME communities". Further, in recognition of the finding that the language, images and concepts used in the campaign were not necessarily meaningful to people from black and minority ethnic communities, 'see me' supported the work of the Glasgow anti-stigma partnership to research and develop materials appropriate for use with Pakistani, Indian, Chinese and African Caribbean communities (Glasgow anti-stigma partnership, 2007). In addition, 'see me' has translated advertisements into Urdu for radio broadcast, paid for media time and supplied interviews for Radio Ramadhan.

10.61 Despite this, consistently across the different phases of the evaluation respondents commented upon the perceived lack of sensitivity within the campaign strands to the diversity of the population, including people who may be subject to multiple sources of discrimination, such as people who are asylum seekers and refugees, and people from black and minority ethnic communities. There was a concern that what counts as the general population is in fact, what one respondent described as "a white indigenous population". Further, while valuing the young people's campaign, including the focus on self-harm it was suggested that the images themselves were what one respondent described as "gender stereotyped". Older people were also felt to have been largely overlooked by the campaign, whether as people who experience stigma and discrimination because of a mental health problem or as a target group for raising awareness.

10.62 While based on an external perception of the campaign, the concerns suggest that: in terms of the process of campaign development; in the ways in which it addresses the stigma and discrimination experienced by people with mental health problems, including people who may also be at risk of other sources of discrimination; and in the ways it raises awareness of mental health, the campaign not only needs to consider issues of diversity and equality, but is also seen to do so. At the very least, it may also underline the need to equality impact assess future activities targeted at addressing the stigma and discrimination experienced by people with mental health problems.

Beyond a public relations campaign?

10.63 As discussed in Chapters 1 and 4, 'see me''s model of change is predicated on a planned progression from awareness raising to attitude change to behaviour change. The focus of the first stage is that of raising awareness, of "making a non issue an issue". The issue raised by several respondents was whether a public relations campaign alone could lead to a deeper understanding. As one respondent remarked, "It will take more than a poster or a cinema ad to change attitudes". A number of respondents suggested the need to follow through the campaigns with a 'call to action'. As one commented, if awareness raising and understanding are not linked to action, "Where does this get you?". As noted above, while organisations may give 'see me' a profile, this does not necessarily follow through to changes in practices. The implications of this for future activities are discussed in Chapters 11 and 13.

Awareness now, but discrimination when?

10.64 Several respondents, while valuing the quality of the campaign, wondered whether, in its attempt not to alienate people, it had in fact been almost "too nice", and what was needed was a stronger statement saying that "stigmatising is wrong" and discrimination illegal. The analogy drawn was with the zero tolerance campaign for addressing domestic abuse. The suggestion made was that a two-track process was needed: a 'promotional' side as well as a "big stick". Arguably by not setting out to change discriminatory behaviours in the first instance and relying on generational change, the campaign potentially leaves unaddressed the discriminatory practices currently being experienced. In the words of one respondent, "is it appropriate to expect people to wait 20 years?"

Strategic objective 2 - Challenging individual incidents of stigma and discrimination

10.65 The second strategic objective of the campaign is to "challenge individual incidents of stigma and discrimination". As discussed in Chapter 4, for the purposes of this objective "individual incidents" of stigma and discrimination refer to negative representations of mental health in the media, not about directly responding to cases of stigma and discrimination experienced by individuals. This objective sets in context the subsequent development of media guidelines, the Media Volunteers Programme and Stigma Stop Watch (see Chapters 5 and 8).

10.66 Stigma Stop Watch is seen by 'see me' as having both a reactive role, in responding to negative reporting, but also a "proactive" role, in preventing negative reporting.

10.67 Key "successes" of Stigma Stop Watch identified by the campaign include:

The response to the complaints made against the Sun for its the "Bonkers Bruno" headline (in relation to Frank Bruno the boxer). This resulted in an apology and an editorial in the Sun and the issue also being picked up by other newspapers;
The role of SSW in contributing to the withdrawal by the Coca Cola company of its advert "Blind dates without the psychos"
A challenge to the derogatory remarks made by John Swinburne, MSP in the context of a debate on the siting of a secure unit
Apologies for the use of derogatory terms in two BBCTV programmes.

10.68 'see me' documents also suggest that Stigma Stop Watch has been used a vehicle for adding weight to local voices. In Lanarkshire, for example, an area where 'see me' and Choose Life had been working with local football clubs, local campaigners complained to 'see me' about the use of derogatory terms in a Soccer Savings advertisement. In response to 'see me''s complaint, the advertisement was retracted and an apology made for the offence caused.

10.69 The work of the media volunteers, described in Chapter 8 above, is a further vehicle for proactively and reactively challenging negative media reporting. The relationships the communications agency seeks to establish with the media were also identified by 'see me' as a route for both responding to and preventing negative representations, including seeking changes in storylines of television soap operas. The media guidelines on reporting suicide and mental health problems also provide a potential resource on which journalists can draw.

10.70 These different vehicles illustrate how active the campaign has been in setting up processes for challenging individual instances of stigma and discrimination, defined largely in terms of media reporting. As discussed above, from the perspective of participants from across the different stakeholder groups across the three phases of the evaluation there had been an improvement in media reporting, particularly when compared with England. The small number of media volunteers interviewed also felt that they had made an impact on the way stories were reported and that there had been a shift in terms of the language used by the press. The difficulty, however, is establishing with any certainty the extent (and sustainability) of any change achieved through these processes. The brief content analysis, for example, described in Chapter 8 suggests that while there had been some change in positive reporting there had been little or no change in negative reporting pre- and post- campaign, though it is recognised that this may be because of the limited scope of the analysis. Notwithstanding the efforts of the research team it has also proved difficult to obtain a sufficiently large sample of media representatives to obtain a real sense of their awareness of, and responses to, the campaign and its work. What did emerge, however, from the small number of media professionals surveyed and interviewed and from a focus group with service users, was the potentially two-edged nature of initiatives such as Stigma Stop Watch. It was suggested, for example, that they may unwittingly provoke the negative responses they are seeking to prevent, for example by media professionals seeking to "make a name" for themselves. Further, that by focusing on outcomes rather than processes these initiatives may not draw attention sufficiently to the media's social responsibilities. From this perspective the service users focus group felt that the emphasis should be more on influencing editors, senior media professionals and owners of the media.

10.71 As noted in Chapter 4, this campaign objective has undergone a subtle shift over time, towards placing less stress on 'see me''s own role in tackling individual instances of stigma and discrimination to one of "promoting a culture" in which "we all challenge" individual incidents. The work the campaign has undertaken with one NHS Board to provide advice on responding to negative reporting about patients, is perhaps illustrative of this shift and may suggest a way forward for creating a climate in which the 'community sanction' or social approbation transfers from those currently stigmatised, towards those who stigmatise through the use of language.

10.72 However, for one respondent a harder edged approach was also required in the form of legislation to prevent the use of inflammatory language. As will be returned to in Chapters 11 and 13, to address both stigma as attitudes, and discrimination as behaviours may even in relation to media representations suggest the need for both a 'stick' and a 'carrot' to effect change.

Strategic objective 3 - To involve people in anti-stigma activities across Scotland at national and local levels and across sectors and communities of interest

10.73 This section explores how effective 'see me' has been in terms of involving people at national and local levels and across sectors and communities of interest. It looks at who 'see me' has developed links with and for what purpose, the different methods utilised for engaging with people and organisations and the barriers and facilitators associated with these and outcomes of these relationships.

Why involve people?

10.74 For 'see me' involving people in the campaign was seen as a way of:

Generating understanding across Scotland of the key issues which affect people with regards to stigma
Building knowledge of different approaches to challenging stigma which are underway across Scotland
Consulting on and obtaining feedback to assist campaign development
Building momentum and infrastructure to roll the campaign out across Scotland
Co-ordinating action and avoiding duplication of effort.

10.75 For these reasons, building relationships with others has been an important component of 'see me''s work, throughout the lifespan of the campaign. In the early days it was thought to be crucial to motivate and encourage others to get involved in 'see me'-related activities to generate widespread "ownership" of the campaign, and in turn maximise the reach of 'see me' messages. Through maintaining contact with key organisations over time, there was also the potential to continuously "drip feed" messages out across Scotland. Thus it was believed that building widespread "grassroots" support was vital to the overall effectiveness of campaign delivery.

Who has been involved

10.76 Potentially, any organisation in Scotland could be involved with 'see me' in anti-stigma activity, whether as an employer, service provider or campaigner. 'see me' staff described working with a wide variety of organisations, across local, regional and national levels. Participants across the three phases of the evaluation also indicated the links they had with 'see me'. Through these discussions, the following sectors and communities have been identified as having some involvement in anti-stigma activities with 'see me';

Mental health organisations

Alliance member organisations, i.e.SAMH, Penumbra, Royal College of Psychiatrists, NSF Scotland, HUG
National Programme partners, e.g. Breathing Space, Choose Life, Healthy Working Lives
Other national mental health agencies, e.g. Depression Alliance Scotland, Mental Health Foundation, Samaritans
Mental health user and carer groups,e.g.VOX, advocacy organisations

Communities of interest

Equalities groups, e.g. National Resource Centre for Ethnic Minority Health, LGBT Youth, DRC
Age related groupse.g. Childline, Young Scot, Age Concern

Sectors

Public sector, e.g.NHS Boards, local authorities, police, universities and colleges
Business sector, e.g. Amey, Standard Life, football clubs, local enterprise companies
Voluntary sector, e.g.CVSs
Media and PR, e.g.IAS Smarts, journalists, Press Data Bureau

Individuals

Elected representatives, e.g. councillors, MSPs, MPs, MEPs
Individual users and carers

UK / International

UK, e.g. Five nations anti-stigma representatives
International links, e.g., IIMHL network

10.77 The nature of the relationships between 'see me' and different organisations and individuals vary enormously, from key campaign delivery partners at one end of the scale, to general information sharing at the other end. Some organisations were viewed by 'see me' to be vital to the overall success of the campaign; Alliance members and IAS Smarts for example. Other relationships varied in their importance depending on the phase of the campaign. For example, links with children and young peoples' organisations were viewed by 'see me' as being particularly important around the development and launch of the 'Cloud Boy' and 'Cloud Girl' campaigns.

10.78 While there was widespread awareness about the campaign, a number of the organisations consulted as part of the evaluation, including those within and outwith the mental health sector, stated that they had no direct involvement with 'see me' at that time. Participants also identified other sectors or organisations that they felt could potentially develop productive links with 'see me' but which, it was believed had not done so to date; these included lawyers, agencies tackling poverty and deprivation and some BME communities.

How relationships are developed

10.79 Involvement in the 'see me' campaign is instigated in a number of ways;

'see me' proactively identifies key partners and localities they wish to work with and targets them directly
Organisations or individuals contact 'see me' for information or advice or suggest working together
Organisations or individuals are directed toward 'see me' by other agencies.

Proactive 'see me' contact

10.80 'see me' staff described employing an 'open door' approach to developing contacts, whereby they prioritise localities or organisations who indicate an interest and commitment to working with them. This approach reflects the limited workforce capacity within the 'see me' team, and a consequential inability to dedicate significant time resources to building relationships where there is no local will to undertake anti-stigma work with 'see me'.

10.81 Organisations or agencies that fit in with the various campaign strands, such as those working with children and young people, may also be actively targeted in the development and implementation phases of the campaign. Not only was this seen by the 'see me' staff team as aiding with consultation and campaign delivery work, but it also helped 'see me' to tap into previously untapped networks. Amey Roads, for example, thought 'see me' saw them as a potential route into other white-collar organisations.

10.82 In return for local or organisational commitment, 'see me' staff described how they would tailor their support to best meet individual needs. This approach was viewed as offering maximum return for the limited input 'see me' was able to invest.

10.83 While the approach of targeting areas where a door was already at least partially open may make efficient use of the small staff team's capacity, it may mean that some hard to reach groups or areas where stigma is entrenched will remain uninvolved because working with these groups is not viewed as practicable. This is an issue for consideration in the future and will be returned to in Chapter 13.

Reactive contacts by 'see me'

10.84 Evidence from the NHS Board survey indicated that 'see me''s involvement in the local activities described by survey respondents was more likely to have been instigated by local areas (53.6%), than by 'see me' (42.9%). Among the organisations taking part in the evaluation a number described instigating contacts with 'see me'. Birchwood Highland, for example, contacted 'see me' to see whether they could benefit from the campaign's PR expertise in their planned anti-stigma bike ride. Amey Roads became involved in 'see me' activities through working with Choose Life in North Lanarkshire.

10.85 The core reasons local areas and organisations gave for getting involved with 'see me' was to use the campaign's input to support and/or guide the development of local anti-stigma activity and raise awareness of stigma and mental health in general. It was also hoped that through undertaking anti-stigma activities in partnership with 'see me' that they could contribute to dispelling some of the myths and fears around mental health problems, and promote more positive images and stories of people with mental health problems. It was also felt that anti-stigma activities involving 'see me' could contribute to other strategic objectives, including mental health awareness, equalities agendas, disability frameworks etc.

Working with local areas

10.86 'see me' staff described how they had sought to develop local champions for 'see me' activity in each NHS Board area. Responsibilities for maintaining connections with key contacts are split between the 'see me' staff team, with different members of the team taking responsibility for different NHS Board areas, and resources have been dedicated to develop these local networks.

10.87 Local Choose Life co-ordinators and Healthy Working Lives co-ordinators can provide potential routes in, although they do not act as lead contact with 'see me' in any area in Scotland. In most localities, as the evidence from the survey of local areas revealed, a representative from within the NHS Board takes a lead.

10.88 As described in Chapter 7, different partnership models have been developed within local areas and between local areas and 'see me' for undertaking anti-stigma work. In Greater Glasgow, a formalised anti-stigma partnership had been set up, involving over 30 organisations, including 'see me', and with dedicated funding from the NHS Board and all key partners. The Greater Glasgow workshop participants described how the relationship with 'see me' had evolved and matured over time into one that had become more equal and mutually supportive, as both parties experience and expertise had developed. In Tayside, Plus Perth, a local mental health service user forum, had led on 'see me' activities locally, and had worked in partnership with other voluntary and statutory services to develop activities. In the Western Isles, partnership working around anti-stigma work had been more problematic because of capacity issues, and a local mental health network had ceased due to staff time constraints.

10.89 The relationship between 'see me' and local areas could vary over time. 'see me' described how links with Grampian had in the past been very strong, but that this had relied on one particularly dedicated individual based within NHS Grampian. When this individual moved roles, the links with the NHS Board area were diminished. This highlights a fragility within the 'see me' structure, where local action is reliant on enthusiasm and prioritisation of anti-stigma work, as opposed to dedicated local 'see me' staff capacity. Where commitment is evident, e.g. Greater Glasgow, then wide partnerships can develop, but where it is not, then the work can be reliant on one or two fragile connections, if any.

Outcome of these activities

10.90 When asked to describe what difference the involvement of 'see me' had on the development of local anti-stigma activities, all but one of the respondents to the NHS Board survey felt that the involvement of 'see me' had a positive impact on local anti-stigma work. Two thirds of respondents (8) stated that at least some of their activities would not have happened without input from 'see me', while over half (7) suggested that 'see me' had helped them to progress with existing anti-stigma work. In four areas, 'see me' was able to make a difference to local work in both of these ways.

10.91 Partnerships between 'see me' and others could enable organisations to build on the PR profile and materials 'see me' has developed, and enable 'see me' to build on local and organisational anti-stigma action. This two-way process could be particularly helpful for 'see me' where organisations developed expertise in particular issues, such as Glasgow has done in working with BME communities. As a consequence 'see me' has been able to benefit from being part of the Glasgow anti-stigma partnership, just as the partnership has benefited from 'see me''s input.

10.92 As noted in Chapter 7, evidence from the NHS Board survey suggests that evaluation may not necessarily be built in to local anti-stigma activities. Nonetheless survey respondents as well as workshop participants described what the perceived impacts of 'see me' in general and on the outcomes of local activities.

10.93 Participants in the local area workshops suggested that 'see me' had raised the profile of the stigma experienced by people with mental health problems to a level that would not have been possible on a local basis. The campaign had made anti-stigma messages visible locally, giving a base on which local activities could build. It was also recognised that the campaign had some "clout" with decision makers, so could be helpful in terms of building buy-in for anti-stigma work in local areas.

10.94 Perceived outcomes of undertaking activities in conjunction with 'see me' could be in terms of professional practice, personal empowerment and making new linkages. In one area, for example, teaching staff were felt to have become more tolerant of mental health issues as a result of working with 'see me'. Within Tayside being involved in designing and running local activities was felt to have empowered service users and increased their self-confidence. Participation in anti-stigma activities could also lead on to other related mental health activities; Amey Roads, for example went on to make links with Healthy Working Lives.

10.95 However, outcomes of working with 'see me' were not always recognisable. A number of evaluation participants, for example, discussed taking part in the round table discussion about BME issues but were not aware themselves of any perceptible further action by 'see me'.

Factors influencing local involvement

Funding

10.96 Funding acted as both a barrier and facilitator to local involvement with 'see me'. Funding had been dedicated within 'see me' to enable the team to network and build links with relevant organisations. Organisations were also able to tap in to some resources from 'see me', which could fund materials or in-kind support from IAS Smarts. When asked about who had funded the local anti-stigma activities described in the NHS Board area survey, respondents indicated that just over half had received some form of funding from 'see me'.

10.97 The availability of funding at local level for anti-stigma work was variable across areas. Some areas, such as Greater Glasgow and Grampian had made a local funding commitment, but this appears to be rare across Scotland as a whole. In other areas capacity may be limited by lack of local funding.

10.98 Funding however was not viewed as such a barrier by the two private sector organisations interviewed in the course of the evaluation. These organisations appeared able to tap into internal resources.

Other policy agendas

10.99 As with funding, other policy agendas could act as both barriers and facilitators to the involvement of individuals and organisations with 'see me'. On a governmental level, the National Programme as a whole was thought to have had an impact on how mental health was viewed in Scotland, to which 'see me' had contributed and from which it had benefited. The National Programme also provided a route for disseminating 'see me' messages. At the same time, however, interviews with representatives from the different delivery agencies suggest that opportunities for joint working between the different vehicles may not be being maximised, either because of limited strategic direction, or because of difficulties finding capacity to undertake joint working.

10.100 On an organisational front, 'see me' had the potential to link in with a range of other policies and strategies, particularly discrimination, equalities and mental health awareness work. 'see me' could be used by different organisations or agencies as a mechanism for meeting commitments with regards to mental health under these strategies; Mental Health Week, for example, was used by organisations in the voluntary and private sectors as a banner under which to undertake 'see me' activities. However, for some of the organisations interviewed, connecting with other policy agendas was described as a potential rather than an actual link. It was thought that there could be additional scope for 'see me' to link in with organisations through related policy agendas.

10.101 However, even given this potential for connecting through related policy agendas, 'see me' continued to face a situation where both anti-stigma work and mental health in general were not always viewed as a high priority, even within equalities, disabilities and social inclusion frameworks. With no obligation placed on public authorities to tackle stigma, it was thought by some participants for it to be too easy for organisations to pass this work off as 'see me''s responsibility alone. Getting anti-stigma activity on to policy agendas through engagement with policy makers and Human Resource structures, for example, was therefore thought to be a high priority for the future.

10.102 Within the broad mental health world, there was also potential for messages and approaches taken by 'see me' to differ or conflict with others. For example, 'see me''s messages around recovery rates, were thought to be too limiting by some, and inappropriate by others ( e.g. for individuals with dementia).

Local champions and strategic buy-in

10.103 It was recognised both in the NHS Board area survey and workshops that the success of local anti-stigma work relied on dedicated and motivated individuals. Good relationships between local organisations and interested parties had the potential to facilitate co-ordination and guidance and build sustainability for the work. Developing positive relationships with local media for example, could also offer opportunities to highlight the 'see me' message.

10.104 Buy-in from management and those at a strategic level was considered to be an important success factor for the development of local anti-stigma activities. Within Glasgow, the local partnership co-ordination role was viewed as vital to the success of anti-stigma work. This role was described as bringing partners together, keeping momentum going, and acting as a champion for anti-stigma work.

10.105 Lack of local capacity to engage in anti-stigma campaigning was viewed as the most significant barrier to the development of activities. Staff shortages in the Western Isles were held to be largely responsible for past anti-stigma work "fizzling out". With the islands described as being stretched and under funded in terms of delivering mental health services, anti-stigma campaigning could take a low priority. For some, mental health awareness and anti-stigma work continued to be perceived as difficult issues for organisations to grapple with and potentially a time intensive exercise.

10.106 Of course, not all anti-stigma activity developed in Scotland is undertaken under the 'see me' banner. Other initiatives by HUG, Positive Mental Health Attitudes, and the WHO Collaboration Centre on Stigma and Discrimination hosted by Health Scotland, provide additional mechanisms for challenging the stigma and discrimination experienced by people with mental health problems. Whilst 'see me' had made connections with all of these initiatives, it is clear that capacity for anti-stigma work across Scotland both includes and extends beyond 'see me'.

'see me' team and structure

10.107 A strong 'see me' brand identity was thought, by some stakeholders, to attract people to work under this banner. Brand profile was thought to give local areas and organisations something to build on with which to "soften people up". Alongside the brand, organisations could also benefit from support from 'see me' staff, including IAS Smarts, to help them develop anti-stigma activities. Evaluation participants particularly valued the PR expertise 'see me' were able to provide.

10.108 The 'see me' management group, as an alliance of different organisations was perceived to provide opportunities for engagement with the campaign through the members' networks. As well recognised mental health organisations the involvement of these organisations was also thought to lend some credibility to the campaign. The fact that the campaign was "owned" by this alliance and not by the Scottish Executive was also thought to be a strength by some within and outwith 'see me'.

10.109 However, participants also identified several limitations of the 'see me' structure. 'see me' was viewed by some as being too central belt based, and not cognisant of issues of stigma in more remote parts. Their location also made outreach to more distant parts of Scotland more difficult. Some participants also suggested a certain "inflexibility" in their approach from time to time, particularly with regards to who could influence the direction and content of the campaign. It was also suggested that partnership working appeared to lean in favour of 'see me''s requirements, as opposed to what organisations and individuals wanted to get out of the relationship. 'see me' is able to provide funding only to those initiatives that contribute to meeting its aims and objectives.

Strategic objective 4 - Ensuring the voices and experiences of users and carers are heard

10.110 The fourth 'see me' objective is "to ensure that the voices and experiences of people with mental health problems and their carers are heard". There was widespread recognition from 'see me', their communications agency, representatives from the media, media volunteers and external agencies that this was an appropriate and important objective for 'see me' to work towards. Processes for involving users and carers relate to all stages of the campaign design, implementation and evaluation process.

Mechanisms for user and carer involvement

User and carer involvement in campaign development

10.111 'see me' described how a number of focus groups were held with users and carers in the early days of the campaign to understand the nature of the stigma users experienced.

10.112 Through their discussions with users and carers it became clear that one hope expressed for the 'see me' campaign was that it would be hard hitting and challenge stigma where users had experienced it directly, particularly within mental health services. This desire diverged from the overarching direction of the 'see me' campaign, which was aimed at the general public, rather than specific sectors within society. Consequently a concern was felt by some within 'see me' that users and carers would not buy in to 'see me''s approach.

10.113Throughout the development of the campaign there has been an ongoing debate about the extent to which 'see me' should take on board the suggestions from users and others in the mental health field about the key messages and direction of the campaign. A number of campaign messages, for example, have been identified by users and carers as priorities for action, particularly stigma within the NHS, and how stigma can affect whole families. However, 'see me''s core task is to eliminate stigma and discrimination through a campaign to change public attitudes and behaviours, and therefore 'see me' takes as its starting point the existing attitude of the public, whilst also seeking to ensure that its representations of stigma and how it impacts on individuals are true to the lived experience of users and carers. 'see me' has taken the view, following an issue-scoping phase, that its campaigns need to be developed around public perceptions and attitudes towards mental health and mental health problems, rather than mental health service users and carers' perceptions about stigma. This raises the question about the extent to which users and carers are able to get involved in 'see me' campaign development. Nevertheless, it was felt by some user and professional participants in this evaluation that there could be more opportunities for users to become involved in campaign development.

10.114 However, it was also argued that if the hard-hitting approach favoured by users at the onset had been adopted, this would have alienated the general public and reduced the likely impact of the campaign as a whole.

User and carer involvement in campaign implementation

10.115 The primary reason given by participants in the evaluation for ensuring the voices of users and carers are heard was to enable the public to learn about the direct experiences of stigma by people with mental health problems and their carers. It was felt that the "authenticity of the first person voice" was considerably more powerful in terms of capturing the media and the public's attention than any other campaign device. Evidence from elsewhere, for example New Zealand, had also indicated that this was an effective mechanism for challenging stigma.

10.116 The two main ways in which users and carers can become involved in campaign implementation are through campaign development phases, evaluation, the media volunteers programme and through local anti-stigma activities.

User and carer involvement in campaign evaluation

10.117 The final phase of the campaign process through which users and carers can make their voices heard is in the campaign evaluation phase. This is undertaken both formally and informally. Informal evaluation mechanisms include feedback from users and carers, for example media volunteer experiences and recommendations, and feedback from the campaign team's regular attendance at local service user led groups and mental health projects.

10.118 Formal evaluation methods involving users and carers have included focus groups, and more recently Hear Me, a nationwide survey aimed at people with direct experience of stigma ('see me', 2007). The survey, which elicited over 1200 responses, asked a range of questions about personal experiences of stigma, and perceptions of the effectiveness of the 'see me' campaign. However, it was recognised by 'see me' that, despite considerable efforts to expand the take-up of the questionnaire and ensure it was received by a range of service users and carers, participants in the survey were self-selecting, and therefore could not be said to represent users and carers as a whole.

User and carer involvement in local activities

10.119 Contacts in local areas make their own decisions whether and how to involve users and carers in campaigns. Nevertheless, local activities do provide an important mechanism for ensuring that the voices of users and carers are heard. Users were involved in over half (16) of the 28 local activities described in the survey. However, only just over one third of all activities (11) involved carers, of which eight activities involved both users and carers. Five activities involved neither group. It could be argued that to meet this strategic objective 'see me' should encourage local areas to involve users and carers in as large a number of activities as possible.

10.120 Three areas which described the steps they had taken to include users and carers in anti-stigma activity were Tayside, Greater Glasgow and Lanarkshire. In Tayside, Plus Perth, a user forum, had taken the lead on local 'see me' activities; a unique situation in Scotland. Users and carers had been involved in many different roles in Perth, and members of the local volleyball team sponsored by 'see me' all had past experiences of mental health problems. In Glasgow, service users described how they had been involved in providing mental health awareness workshops, using their own experiences of stigma to educate others. In Lanarkshire, users and carers have participated in training future health professionals at Bell College through contributions to lecturers.

10.121 Involvement in anti-stigma work was viewed positively by user participants in the workshops, and service users suggested that they felt empowered and more confident due to their involvement. User and carer groups were also thought to be a good mechanism for taking forward anti-stigma work as they did not face some of the constraints around campaigning that other organisations and agencies could face.

Other mechanisms for ensuring users' and carers' voices are heard

10.122 In addition to the mechanisms described above, users and carers can take up other opportunities from 'see me' to share their experiences and perspectives. These include submitting one's own testimony through the 'see me' website, and getting involved in the Stigma Stop Watch campaign.

Media volunteers

10.123 The 'see me' media volunteer programme provides the central structure for collating and disseminating first hand experiences of mental health problems, stigma and recovery. Chapters 5 and 8 have illustrated how the media volunteers are recruited and trained, and the process through which they work with the media.

10.124 All of the media volunteers interviewed indicated that they had the opportunity to convey the messages they wanted to, including the every day experience of living with a mental health problem, that recovery is possible and how stigma can affect individuals.

10.125 There has been an ongoing need by 'see me' to recruit volunteers. The media volunteers are not a static group: some who have shown an interest in becoming a volunteer drop out at, or before, the training phase; other individuals volunteer for a while, but then move on for various reasons; some volunteers stay for the long term. IAS Smarts indicated that drop out became a particular issue for them when recruiting media volunteers for the Young Peoples' campaign. It transpired that young people in general, and young men in particular, were more likely to drop out of the training than older volunteers.

10.126 However, given this on-going recruitment, a number of gaps in media volunteer provision have still been identified. 'see me' indicated that it experienced under-representation in terms of BME perspectives, and volunteers have also not been recruited from certain parts of the country, such as the Western Isles, reducing the potential to ensure that voices from these communities are heard. Although not strictly related to the media volunteer programme, it was also suggested that the opportunities to hear the experiences of celebrities with mental health problems had perhaps been under-explored by 'see me' over the years.

10.127 The media volunteers themselves, through sharing their own experiences, were thought to be an effective mechanism for encouraging others to speak out about their experiences of mental health issues and stigma. The volunteers indicated that this outcome had been conveyed though feedback they had received in response to particular stories in the media in which a media volunteer had featured.

10.128 To enable the media volunteers to convey their messages, systems developed for recruitment, training, and media liaison appear largely to work well and to provide an effective, safe and supportive means to enable people with mental health problems to speak to the media. Other organisations and elements of the National Programme facilitate the recruitment of media volunteers, through access to their networks. In terms of media liaison it was thought by the media volunteers to be important that 'see me' could challenge the media if there was any element of the story that the volunteers were unhappy with, and demand changes if required. It was felt by IAS Smarts that such interventions by 'see me' were only possible because a good and mutually beneficial relationship had developed between 'see me' and certain media in Scotland.

10.129 Clearly, evidence suggests that 'see me' has developed expertise in relation to working with the media volunteers: an expertise that has also benefited other mental health organisations and initiatives ( e.g. Depression Alliance Scotland, Choose Life) wishing to encourage people with mental health problems to work with the media. A number of learning points did, however, emerge from the evaluation. First, the difficulty of developing a media volunteer process which appropriately protects people without becoming too rigid or bureaucratic, or coming to be perceived as patronising toward volunteers, especially those who already have more experience of media work.

10.130 Second, the difficulties of matching supply and demand. Media volunteers noted, for example, that not all approaches made by the media were taken up. This may be because 'see me' made the decision that it was not an appropriate story for the media volunteers to participate in, or because there were no media volunteers available. However, cases also occurred where media volunteers participated in an interview with a journalist, only for that story not go to press, or be broadcast. While not directly under the control of 'see me', this nonetheless does impact on the media volunteers who act on behalf of the campaign, and to whom 'see me' has a responsibility. IAS Smarts also indicated that the media could, for whatever reason, be more interested in one person's story than another's. In the case of the young peoples' campaign strand; there was particular interest by the media in one young woman's story, which put some additional pressure on that volunteer.

10.131 Third, in terms of recruitment, stigma itself could still act as a barrier against some people coming forward to speak to the media. As noted above, when trying to recruit volunteers to support the young people's campaign strand the drop out rate for the young people, and particularly young men, was higher than usual. It was felt that stigma was a key factor in this drop out rate. Stigma could also be a factor affecting young carers who might want to speak out as well. One outcome of this stigma was that there was a smaller pool of volunteers for the Young Peoples' campaign than anticipated.

The extent to which the objective of involving users and carers has been realised

10.132 The evidence presented here illustrates the nature of the activity which has taken place under the 'see me' banner to ensure that the voices and experiences of users and carers are heard, both by 'see me' themselves, and by the general population through media work and local activities. Nonetheless the data do raise a number of questions:

Do the media volunteers' messages broadly represent those expressed by users and carers across Scotland in relation to stigma?
Does 'see me' as a whole reflect the issues that users and carers are expressing with regards to priorities in terms of tackling stigma?
Are there adequate mechanisms for ensuring user and carer input into 'see me'?

10.133 In relation to the first question, it is clear that the mechanisms for recruiting volunteers through the management group members' networks, a range of mental health projects, and other local contacts opens opportunities to a wide range of individuals across Scotland. There is also the opportunity to register interest in becoming a media volunteer through the website or through contacting 'see me' in person. However, these mechanisms may only reach those who already have some links with 'see me', and may not ensure the recruitment of volunteers from the different geographic communities or communities of interest in Scotland. It is not a key aim of the media volunteer pool to be representative, but rather to support the campaign in its work with the media by providing first-person testimony related to the strands that 'see me' has adopted. Whilst seeking to make the pool as representative as possible, 'see me' avoids recruiting people whose testimonies will not be used, as this potentially creates false expectations and disappointment. Nevertheless, there was a perception that some voices may not be being heard, including, for example, those of carers, people from BME communities and island communities. It may be that these groups, as with young men, are ones where stigma is most keenly felt, and therefore are deterred from getting involved.

10.134 In relation to the second question, a number of external agencies and user participants in the evaluation suggested that there were too few opportunities for users and carers to get involved in decision-making processes with relation to 'see me' campaign development. The recent 'Hear Me' survey ('see me', 2007) has provided a large scale feedback route, but it was acknowledged that this was a self selecting sample who were likely to be engaged with 'see me' already, despite the fact that 'see me' had worked hard to extend the reach of those who responded by contacting mental health professionals across the country and seeking to contact those who were not involved in mental health projects or even users of services. There is also a recognisable tension which exists at the heart of 'see me' in terms of balancing out the need to ensure the views of users and carers about stigma and the campaign are heard, while at the same time developing a campaign targeted at a different audience.

10.135 In relation to the third question, one clear route through which users and carers can and do get involved with 'see me' is through local anti-stigma activity. At present many activities involve users, and some involve carers, but this is not universal across Scotland. There may therefore be scope for users and carers becoming more involved in organising and participating in local anti-stigma action.

Strategic objective 5 - Promoting a culture of learning and evaluation through all its work, so that effectiveness can be demonstrated and lessons shared

10.136 'see me''s fifth objective aimed to promote a culture of learning and evaluation to both demonstrate effectiveness and for lessons to be shared. Perhaps even more than is the case with the other objectives, it is difficult to measure in any hard and fast way the extent to which 'see me' has been able to promote a "culture of learning and evaluation". For the purposes of the evaluation it has been taken to comprise three dimensions:

Learning and evaluation to inform the on-going direction of the campaign
Sharing learning and evaluation with others
Learning from others.

Learning and sharing to inform campaign development

10.137 In terms of the first dimension, learning and evaluation to shape the on-going direction of the campaign, the documentary data and interviews with those directly involved managerially and operationally with 'see me' indicate the significance attached to: the process of pre-campaign learning and research through focus groups and roundtable discussions, stakeholder interviews, literature reviews creative testing; and post-campaign evaluation.

10.138 As intimated in the previous section, although testing and evaluation has informed the campaign, there does not appear to have been a systematic consideration of the different groups included (or excluded). For example by considering the potential differences in the issues raised by focus groups in relation to gender, sexuality or ethnicity (which might have associations with previous/other experience of stigma and discrimination) and by considering how messages needed to be tailored accordingly. This, however, is not to undermine the strong within-campaign culture of evaluation, but to suggest a need to perhaps look more critically at how the process is implemented: the inclusions, exclusions, and how the findings are interpreted.

Sharing and learning with others

10.139 Sharing and learning with others has three elements. First, a broadly public relations element as part of keeping the campaign profile high. 'see me' has been active in publicising its own achievements through, for example: ' see me… so far' ('see me', 2006), its own review of the first four years of the campaign; articles, for example in Mental Health Today (March 2005); and activities such as its submission to the Institute of Practitioners in Advertising ( IPA) Effectiveness Awards in 2003, for which the campaign won a bronze award.

10.140 Making available research and evaluation evidence is a second element of sharing with others. Several respondents interviewed in the course of phases 1 and 2 of the evaluation, for example, cited the campaign's capacity to generate research as one of the strengths of a national body. One respondent described using statistics made available by 'see me' in training and workshops.

10.141 A third dimension of sharing with others is the learning for other campaigns outwith Scotland. The recently funded Moving People campaign in England drew on learning from Scotland to make the case for an anti-stigma campaign in England. 'see me' respondents also described both formal international recognition, but also uncited 'borrowing' of their ideas.

10.142 One respondent interviewed in phase 2 of the evaluation also referred to the learning for the anti-poverty field for the way the campaign has directed its attentions at whole populations to tackle discriminatory beliefs. This respondent felt this approach to challenging beliefs also needed to be done in anti-poverty work.

10.143 Where there has been less evidence of a 'trickle down' effect of learning and evaluation has been in respect of local or organisation-specific initiatives. The NHS Board survey, undertaken as part of the evaluation, did not ask what evidence base informed the different activities, nor the input 'see me' had made into this evidence base. While a number of case studies do exist, the point made in the course of the area workshop in Glasgow was that in fact there was little evidence upon which to draw. To help build up this evidence base Glasgow was building evaluation into its activities from the start. As indicated in Chapter 7, the NHS Board survey revealed that only just over one-third of activities had been evaluated. The comments of several interviewees describing initiatives within their own organisations also suggested that these had not been formally evaluated.

10.144 This suggests the potential for 'see me' in helping to inform the evidence base informing the range of activities. It also points to a possible role for the campaign in encouraging local areas to build evaluation into their activities, where practicable, to help develop learning of 'what works'.

Learning from others

10.145 In its developmental stages, 'see me' drew on the models of other international anti-stigma campaigns. It is not clear, however, whether models from other equalities or anti-discrimination activities outwith mental health have been drawn upon to inform the campaign's development.

10.146 As the acknowledged experts within Scotland, 'see me' can clearly play a lead in developing the evidence base, but there may also be scope for a two-way flow, from the centre out and from the local areas to the centre: both to inform the national campaign's activities, but also to act as a repository for shared learning across Scotland and beyond, to support the development of the research and evidence base, and in that way more proactively promote a wider culture of learning and evaluation.

Key Points

National and specially commissioned surveys over the period 2002-2006 reveal positive shifts in mental heath awareness and in attitudes towards mental health problems. The number of other related initiatives over this period make it difficult to determine 'see me''s specific contribution, but the data may suggest the value of a number of different initiatives working in parallel to effect change.
The surveys also indicate the high levels of campaign awareness, with over one-third of the population surveyed in 2006 aware of the 'see me' name. Awareness is particularly high among people with direct experience of mental health problems.
Qualitative data collected in the course of the evaluation suggest that among those interviewed campaign awareness was high, and the perceived impacts positive.
The perceptions of those interviewed also raised a number of questions with implications for the future direction of the campaign, in particular the need to consider the perception that some 'equalities' groups have been unwittingly excluded from the campaign development and implementation.

In terms of affecting media reporting, the Stigma Stop Watch process demonstrated some successful outcomes. Media volunteers felt that they had been able to effect a shift in the way the media presented mental health related stories. Across the range of different stakeholder groups interviewed in the course of the evaluation there was a perception that media reporting in Scotland had improved, compared with that in England.
The NHS Board area survey revealed the different partnership arrangements put in place to deliver anti-stigma activity. In part these differences reflect local circumstances, but they are also influenced by the different barriers and facilitators each area faces, including funding, policy priorities, management or strategic buy-in, and local capacity.

Whether as media volunteers and/or as participants in campaign design and implementation, 'see me' has sought to develop mechanisms for giving a voice to users and carers. In addition, in some areas at least, users and, to a lesser extent, carers were involved in local anti-stigma activities. The scope for broadening the pool of media volunteers to include those from different communities of interest and geographical communities was suggested.

'see me' has a strong within-campaign culture of evaluation. There may, however, be scope for more nuanced analysis of research and evaluations, to ensure that any differences, for example in experiences of stigma in relation to gender, sexuality or ethnicity, that may be important to campaign development or assessing campaign outcomes are identified.
There is less evidence of this culture extending to local areas. There may be scope for 'see me' to advise on research and evaluation as well as act as a resource on the evidence base to inform local actions.

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Evaluation of 'see me' - the National Scottish Campaign Against the Stigma and Discrimination Associated with Mental Ill-Health

CHAPTER TEN ASSESSING EFFECTIVENESS