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CHAPTER TWELVE CONCLUSIONS
Introduction
12.1 The three aims of the evaluation were to:
- Co-ordinate a detailed account of the development and activities of the 'see me' campaign
- Determine the extent to which the campaign has met its own strategic objectives, including identifying factors that have acted as facilitators or barriers
- On the basis of the findings to make recommendations for the future development of anti-stigma work in Scotland.
12.2 Drawing together the themes emerging from the evaluation this chapter assesses what the campaign has achieved in terms of its own strategic objectives and the factors, including those relating to its strategic and operational development that have supported the realisation of these objectives or acted as barriers.
What has been achieved?
12.3 'see me' has been a groundbreaking campaign, responding to long standing concerns within the mental health community in Scotland that action needed to be taken to address stigma. It has acted as a galvanizing force for this community giving it a strong identity, voice and sense of value. 'see me' has been a high-energy campaign, generating a breadth of different activities that have drawn attention to the impact of stigma on the lives of people who experience mental health problems. It has also made a significant contribution to an understanding of the processes for combating stigma in a public mental health context.
12.4 A number of factors have, however, made it difficult to assess the specific extent to which 'see me' has met its own aspirations. The first factor impeding firm conclusions is the comparatively 'soft edged' and qualitative nature of the campaign's objectives and the absence of measurable outcomes against which to gauge impact. Second, in relation to the campaign's main objective of tackling 'stigma and discrimination by raising public awareness of how both affect individuals with mental health problems, and by improving public understanding of mental health', there is the difficulty of attributing change - positive, negative or absent - specifically or primarily to the campaign. The broad-based nature of this objective does not elucidate what lies within and outwith the remit of the campaign. This makes it difficult to differentiate and distinguish the role of the campaign from the role of other agencies and organisations and consequently to attribute responsibility both for achievements and for areas where there has been no change (or indeed where change may be in a negative direction). As discussed in Chapter 13, this would suggest that, in future work on stigma and discrimination, there needs to be greater clarity about what the campaign itself can and cannot do, about the roles of other agencies and organisations, and the relationships between the campaign and these other stakeholders.
12.5 Third, and related to this question of attribution is the impact of legislative and policy initiatives relating to mental health problems and mental health awareness that have been developing in parallel with the evolution of 'see me' (see Chapters 1 and 13), and which may collectively contribute to effecting change in attitudes and behaviours.
12.6 Notwithstanding these difficulties of precise measurement and attribution it is possible to draw out the following themes suggestive of the effectiveness of the campaign in its own terms over the period 2002-2006.
Tackling stigma and discrimination by raising public awareness of how both affect individuals with mental health problems, and by improving public understanding of mental health
12.7 The qualitative and quantitative data collected from other sources and in the course of the evaluation suggest that there have been changes in expressed attitudes in Scotland towards people with mental health problems over the period 2002-2006. Although, as noted above, this could be the combined effect of a number of influences, there is no doubt that 'see me' has been able to generate 'noise' (in a positive sense) at the general population level, to which the different initiatives can add within their own specific contexts. This is corroborated by the perceived greater openness or willingness to talk about mental health problems (stress or depression in particular), referred to by a number of participants interviewed in the course of the evaluation.
12.8 The campaign is therefore critical to creating a high-level profile and identity to activities aimed at increasing awareness and drawing attention to the stigma and discrimination experienced by people with mental health problems.
12.9 However, for those interviewed in the course of the evaluation, the model adopted by 'see me' raised several significant issues which pose challenges for future work to address stigma and discrimination. First, while the campaign saw itself as seeking to include people from diverse communities in its development work and campaign activity, those viewing the campaign from outwith, including those working with different equalities groups, perceived that the approaches adopted did not fully reflect the heterogeneity of Scotland's population or the multiple sources of discrimination and stigma to which some groups of people are exposed, nor was it perceived to have been 'equality proofed'. A key question for consideration, therefore, is whether a 'general population' campaign approach risks systematically excluding people already exposed to double or triple jeopardy: at risk of experiencing stigma and discrimination both on the grounds of a mental health problem and some other aspect of their social identity.
12.10 Second, the perceived focus of the campaign on individual action and attitudes was seen as potentially letting institutions "off the hook" in terms of recognising their own responsibilities. This has particular implications if the emphasis is on discrimination ( i.e. active unequal treatment in terms of access to employment, goods and services, including health and social care) and the ways in which organisational practices and processes may systematically exclude people with mental health problems.
12.11 A further, fundamental question which arose from the evaluation was whether increased awareness and changes in expressed attitudes towards people with mental health problems can be automatically assumed to be a precursor to changes in behaviours. As noted at a number of points in the course of the evaluation 'see me''s change model is predicated on the assumption that awareness informs attitudes which then inform behaviours: a shift anticipated to take a generation. As discussed in Chapter 6, the social marketing model adopted and adapted by 'see me' has provided a strong structure and process for the development and implementation of the campaign, and one which has enabled the campaign to hold the line in terms of direction of travel, in the face of others' expectations or demands. In terms of outcomes, however, as Stead et al (2007) note in their assessment of 'see me' as a social marketing campaign, "there is no real demonstration of behavioural change". Further the report of the most recent "Well? What do you think?' survey notes "…stigma is fairly complex in nature, and that while campaigns and initiatives may be helping to change attitudes, there may still be some way to go before this is reflected in changing behaviour" (Braunholtz et al, 2007, p.102, emphasis in original).
12.12 Clearly, as noted above, achieving change at the level of behaviours is a long-term and complex process, requiring actions at different levels, and drawing on different approaches. Reflecting this complexity, Chapter 13 below proposes a multi-dimensional model that incorporates a social marketing element as one important component of a strategic, whole systems approach to tackling both stigma and discrimination.
Challenging individual incidents of stigma and discrimination
12.13 For 'see me' the objective of challenging individual instances of stigma and discrimination relates to preventing or reacting to negative media representations of mental health. The media volunteers programme, Stigma Stop Watch, media guidelines and liaison with individual media professionals aim to address this objective.
12.14 Stigma Stop Watch has provided a very visible vehicle for co-ordinated action that would not otherwise be available. Media volunteers also felt that they had been a force for good. Across the different phases of the evaluation the perception of those interviewed was that media reporting in Scotland had improved, particularly compared with England. What this may suggest is that, while not necessarily yet quantifiable, 'see me' has had an important role in creating an environment in which it becomes increasingly socially unacceptable to use derogatory terms or negative storylines (fictional or factual) through its pincer movement of positive endorsement and the 'stick' of public challenge.
Involving people in anti-stigma activities across Scotland at national and local levels and across sectors and communities of interest
12.15 'see me' has undoubtedly sought to engage with different agencies and sectors across Scotland. As the NHS Board survey, for example, suggests, most areas in Scotland have undertaken at least one anti-stigma activity. The responses also suggest that 'see me''s involvement was valued for its expertise and support as well as for the materials and resources it was able to provide. The survey also revealed that a significant proportion of these activities would not have happened, or would not have been so successful without the campaign. It is, though, not just the practical aspects of 'see me' that are important, but the validity and reinforcement it provides for local areas seeking to effect change within their own communities.
12.16 To encourage this level of local buy-in, the campaign has adopted a strategy of 'knocking on open doors'. This has clearly been a productive mechanism in the early stages of the campaign and an efficient way of using staff, particularly given the contained size of the operational arm of the campaign (see Chapter 5). For the future, however, consideration may need to be given to methods of engagement with those behind 'closed doors' or environments where there is no product champion or local buy-in.
12.17 As noted in Chapter 4, funding was not made available to the campaign to support a network of local co-ordinators. Further, the data suggest that there may have been a degree of trade-off between national campaigning and local community development work. This may be compounded at local level by limited funding to support this activity, particularly in the context of a lack of strategic buy-in or competing priorities.
12.18 What also emerged from the evaluation is that 'involving' has tended to be about getting buy-in to a branded social marketing campaign. While this branded approach is important in the first stages of a campaign to get a strong coherent message across, it does perhaps raise questions about the long-term sustainability and mainstreaming of actions to address the stigma and discrimination experienced by people with mental health problems. If the focus shifts to the harder-to-reach environments, a less strongly branded approach and one able to be flexible to others' agendas may be required.
Ensuring that the voices and experiences of people with mental health problems and their carers are heard
12.19 In the context of 'see me', ensuring the voices of users and carers are heard has two dimensions: being 'heard' within the campaign through focus groups and surveys; and being heard by others through media volunteers, Stigma Stop Watch and local anti-stigma work. The campaign has been proactive along both dimensions. Focus groups have been held with users and carers as part of the campaign development process, surveys to support the workplace campaign, and the large self-report survey 'Hear Me' ('see me', 2007). In addition, the media volunteer programme provides a vehicle for people to talk about their experiences. Funding limitations were felt by those running the campaign to have precluded setting up a 'speakers' bureau' of volunteers able to contribute to training or to talk to sectors in addition to the media, such as employers.
12.20 At local level, the NHS Board survey suggests that the patterns of service user and carer involvement are variable. In Tayside, for example, anti-stigma work is led by a user forum, in other places users and carers have been directly involved in delivering different initiatives, elsewhere users and particularly carers may have had no involvement. This may suggest scope for 'see me' to support and encourage greater user and carer involvement at local area level.
12.21 What also became evident in the context of the campaign development is a tension between seeking the views of users and carers and developing a campaign targeted at a different audience. In the early stages of the campaign, for example, users suggested that they wanted a hard hitting campaign, whilst those involved in developing the campaign felt this would alienate the general population. Notwithstanding the voluntary organisations represented on the 'see me' management group this tension may indirectly highlight a difference between a consumer-led campaign 'owned by' and directly representing or articulating the voices of experience of users and carers, and one which, despite the involvement of service users and carers in different capacities, has a more mediatory role, seeking to inform people about the experiences of users and carers or speak on their behalf.
Promoting a culture of learning and evaluation through all its work, so that effectiveness can be demonstrated and lessons shared
12.22 The fifth strategic objective aims to promote a culture of learning and evaluation. As described in Chapter 6, campaign strands go through an extensive development process. In addition research is commissioned to support campaign arguments. Evaluations of the reach and recall of two of the campaign strands were also commissioned by 'see me'. This commitment to research and evaluation is an important model for other anti-stigma and discrimination campaigns. The need to embed evaluation has not however trickled down to the local areas. This may be a function of the availability of resources at local level, but in terms of creating a 'culture' of learning and evaluation, it may suggest a role for 'see me', in conjunction with NHS Health Scotland, to support local areas to undertake evaluations as well as providing an evidence base for different types of activity.
12.23 What could also be further developed is a two-way flow, not just from 'see me' but from local areas to 'see me'. There may also be opportunities for shared learning with other anti-stigma and discrimination initiatives outwith mental health.
Factors that have supported or acted as barriers to the realisation of 'see me''s objectives
12.24 As noted above, not all the factors that have supported the realisation of 'see me''s objectives or which have acted as barriers, lie within 'see me''s control. The wider policy environment of which the campaign is a key part will also contribute to effecting changes in attitudes towards mental health and people with mental health problems. Similarly, factors that have acted as potential obstacles, such as lack of capacity at local area level to take forward anti-stigma activities are outwith the campaign's control. These external factors reinforce the need for a strategic approach to addressing stigma and discrimination that encompasses, but extends beyond 'see me'. This is explored further in Chapter 13.
Factors that have acted as barriers to achieving the campaign's objectives
12.25 Although the evaluation was not asked to address the cost effectiveness of the campaign the question of resources did inevitably arise in the course of the research. At an operational level, it was suggested by 'see me' that certain initiatives, such as the 'speakers' bureau', could not be pursued. More strategically, the perception held by respondents from outwith 'see me', that there had been some loss of momentum in the campaign over time, may suggest that there has had to be a trade-off between a high profile, national level campaign, and local level community development. Both, however, are needed to sustain and embed activities to address the stigma and discrimination experienced by people with mental health problems.
12.26 While not a 'barrier' as such, the evaluation suggests that the nature and quality of the campaign's external relationships have had an influence on its ability to achieve its objectives. The relative autonomy of the campaign from the Scottish Executive has both advantages and drawbacks. In addition, its relative separateness or 'stand-aloneness' both from other elements of mental health improvement activity and from the wider social justice agenda, are features which may warrant further consideration. Further, at the local level the sense is that the campaign may be 'bolted' on to local activities as a 'product'. The challenge for the future will be to ensure that the campaign can act as a catalyst for broad-based actions that extend and deepen the work of tackling discrimination and stigma and avoid the risk of seeing the marketing of the 'see me' brand or product as an end itself.
Factors that have facilitated the achievement of the campaign's objectives
12.27 The campaign has made an important contribution to creating and supporting a cultural shift. It has provided an identity and validity for work in Scotland to address the stigma and discrimination experienced by people with mental health problems. It has also given impetus to local activities where there is capacity to take this forward.
12.28 The evaluation suggests that it has achieved this through a clear sense of its own purpose and direction, both strategically and operationally. The tight relationships that have evolved within the management group, the commitment to a coherent process, strong internal integration and a shared belief at strategic and management levels in the importance and value of what they are seeking to achieve, together with high energy levels have undoubtedly enabled the campaign to undertake a considerable breadth and depth of work. Operationally, the creative design work, both in product development and implementation, has provided a strong visual identity. For those outwith the campaign the hallmarks of 'see me' were its professionalism, skill and expertise.
12.29 In terms of its 'location', the independence of the campaign from the Government was felt to have given greater credibility, and also more freedom of action than a more centrally controlled campaign. Strategically, as the discussion in Chapter 4 suggests, the campaign has been able to evolve, drawing on the expertise of the management group and feedback from the field. This independence is, however, relative; as funder, the Scottish Executive has also fed into the strategic decision-making processes. Further, the shift in the Scottish Executive representative's role in the management of the campaign from that of 'observer' status to that of 'performance management', indicates the inherent tensions faced by an independent, 'arms length' delivery vehicle with a strong sense of its own autonomy and purpose, but wholly reliant on public funds.
Looking ahead
12.30 'see me' has been a significant force for change in Scotland, acting as both a powerful focal point and a resource for beginning to tackle the stigma and discrimination which excludes people with mental health problems from participating as equal citizens. It has also drawn attention to the complexities of seeking to change the attitudes and behaviours that result in this exclusion. As one evaluation respondent commented, while it has been a "job well done" it was also not yet a case of "job done".
Key points
- The campaign has been critical to giving a high-level profile and identity to activities aimed at increasing mental health awareness and drawing attention to the stigma and discrimination experienced by people with mental health problems. It has been important in creating a background 'noise' around these issues, to which other initiatives can add within their own contexts. Issues for the future include further consideration of issues of equality and diversity in campaign design and delivery; and the need to consider ways for addressing discrimination, not just at an individual level, but also as it is embedded in the processes and practices of organisations and agencies.
- In terms of media reporting, the campaign has had an important role in creating an environment in which it becomes increasingly unacceptable to use derogatory terms or negative story lines in relation to mental health or people with mental health problems.
- The campaign has encouraged a breadth of local activity. Developing an approach of 'knocking on open doors' has been productive in the early stage, but different processes of engagement may need to be considered in those areas still behind 'closed doors'.
- 'see me' has sought to give a voice to users and carers. There may be scope for local areas to involve users and carers to a greater extent in activities aimed at addressing stigma and discrimination.
- The campaign has developed its own culture of learning and evaluation. This has not yet trickled down to local areas. There may be potential for 'see me', together with NHS Health Scotland, to foster a similar culture at local levels.
- Factors within the campaign that have supported the realisation of the campaign's objectives include: a clear sense of purpose and direction, strategically and operationally; its professionalism, skills, expertise; and its relative independence from the Scottish Executive.
- Factors, within 'see me''s environment that may have limited realisation of its objectives include the level of campaign funding, which may have meant some activities have not been developed. The funding levels may also have created a tension between providing a national campaign and embedding action at local level.
- To sustain the gains that 'see me' has achieved, together with its partners at local and national level, requires a strategic approach which places 'see me' at its heart to provide leadership while also encouraging others to take responsibility for overcoming the inequalities and systematic exclusions people with mental health problems continue to experience.
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