Evaluation of Antistigma Interventions With Sixth-Grade Students: A School-Based Field Experiment
Abstract
Objective:
School-based interventions for preadolescents provide the opportunity, in a ubiquitous institutional setting, to attack stigmatizing attitudes before they are firmly entrenched, and thus they may reduce mental illness stigma in the overall population. This study evaluated the effectiveness of classroom-based interventions in reducing stigma and increasing understanding of mental illness and positive attitudes toward treatment seeking among sixth-grade students.
Methods:
In an ethnically and racially diverse sample (N=721), 40% of participants were Latino, 26% were white, and 24% were African American; the mean age was 11.5. In a fully crossed design, classrooms from a school district in Texas were randomly assigned to receive all three, two, one, or none of the following interventions: a PowerPoint- and discussion-based curriculum, contact with two college students who described their experiences with mental illness, and exposure to antistigma printed materials. Standard and vignette-based quantitative measures of mental health knowledge and attitudes, social distance, and help-seeking attitudes were assessed pre- and postintervention.
Results:
Printed materials had no significant effects on outcomes and were grouped with the control condition for analysis. For eight of 13 outcomes, the curriculum-only group reported significantly more positive outcomes than the control group; the largest between-group differences were for stigma awareness and action, recognition of mental illness in the vignettes, and positive orientation to treatment. The contact-alone group reported significantly more positive outcomes on three vignette-based measures.
Conclusions:
Results were most promising for a classroom-based curriculum that can be relatively easily disseminated to and delivered by teachers, offering the potential for broad application in the population.
Stigma critically influences the well-being and recovery of people with mental illnesses, affecting employment, income, social ties, quality of life, mastery, self-esteem, depressive symptoms, and access to medical and mental health services (1–15). In recognition of this problem, there has been a sustained effort to reduce stigma by educating the public about neurobiological bases of mental illnesses and available treatments, with the assumption that framing mental disorders as medically treatable “illnesses like any other” would reduce stigma (16–19). There is clear evidence that the public has adopted this understanding and that mental health treatment is increasingly viewed as beneficial (20–22) and sought by the public (23).
Nevertheless, these changes have not been accompanied by stigma reduction. Core aspects of stigma—emotional reactions, stereotypes, and social distance—remain unchanged or have worsened (20,21,24). What can explain this discrepancy? Research now shows that biological explanations tend to increase rather than decrease stigma (25–27). Thus it may be necessary to address stigma directly rather than by changing causal beliefs. Stigmatizing attitudes and behaviors may also be harder to change than causal beliefs because the former involve emotions and can have personal consequences. Addressing these attitudes before they are firmly set may be a promising approach to reducing stigma, with evidence suggesting that stigmatization occurs as early as childhood and adolescence (28–35). Therefore, the study reported here evaluated the effectiveness of a school-based intervention that directly focuses on stigma. Education- and contact-based interventions can reduce stigmatizing attitudes and behavioral intentions. Most studies focus on adults; fewer target adolescents (36–40). We located only six studies that targeted pre–high school youths (41–46). These studies, with samples ranging from 185 to 1,500 in more than 16 states, found significant reductions in stigma among youths between third and eighth grades. All employed a curriculum of some sort; one also included a contact intervention. Three studies included follow-ups of three to six months; three employed control conditions.
We implemented interventions designed to improve knowledge, attitudes, behavioral intentions, and behaviors about mental illness and help seeking among sixth-graders. To develop a stigma intervention that can be broadly disseminated, we evaluated a classroom-based curriculum, which was designed to appeal to teachers and students and easy for teachers to implement without specialized training. We also evaluated the effectiveness of a contact intervention and of an intervention in which classrooms were saturated with antistigma materials. Several aspects of social and psychological development led us to target sixth-graders rather than younger children. Preadolescents begin to understand that others have thoughts and feelings different from their own; preadolescents also include interpersonal and psychological features in their understanding of themselves and others and experience heightened social comparison (47).
In addition to augmenting a very small body of research, several strengths of the study allowed it to meaningfully extend what can be concluded from the existing literature. As in our study, previous studies have used a teacher-administered curriculum that does not entail extensive teacher training, suggesting that a relatively easily disseminated curriculum can reduce stigma. However, most of the previous studies relied on samples that involved teacher self-selection, allowing the possibility that effects will be found only when teachers favor an antistigma agenda. In our study, self-selection played a role at the school level but not the classroom level, which likely introduced less bias. Ours is the only study to include a fidelity measure, which allowed us to evaluate how faithfully the intervention was enacted in the classroom and whether fidelity was related to outcomes of the intervention. Finally, although our sample came from a single geographic locale, it provided excellent representation of the major racial-ethnic groups in the United States. All these features raise optimism that any reductions in stigma we found can generalize to the broad population.
Additional strengths introduced in this study include the evaluation of multiple interventions. Three of the previous studies included a control condition; however, in all but one case, the control condition was usual instruction. This leaves open the possibility that intervention per se—via novelty, special attention, and so forth—rather than intervention content produced attitude change. By testing three interventions, we were able to compare their effectiveness and attribute change to a particular intervention as opposed to intervention per se. Finally, by including vignettes describing specific disorders, we were able to assess changes in responses to these disorders as well as the more typical approach that focuses on the generic concept of “mental illness.”
Methods
Study Design
The delivery of the three interventions was independently varied in a fully crossed design, resulting in eight experimental cells, including a control group that received no interventions (Table 1). Sixteen middle schools (with separate zip codes) from an urban school district in Texas were ranked according to performance on the statewide standardized assessment of math, English, and science. Rankings based on percentage of families below the poverty line were nearly identical. We randomly assigned the top eight schools to one of eight cells; the bottom-ranked eight schools were then assigned to a cell in the reverse order so that, for example, the top- and bottom-ranked schools were paired. Each cell (two schools in each) was randomly assigned to a study condition. Before the study began, two schools dropped out for non–study-related reasons. The study was repeated during a second academic year with a new set of sixth-grade students in five of the original schools chosen because they had demographic characteristics similar to the lost schools. Thus a total of 19 classes from 14 schools were included in the study. There were no significant differences in sociodemographic characteristics between repeated and nonrepeated classrooms (results available on request).
| Group | Intervention | Students who passed a statewide standardized test (%) | ||||
|---|---|---|---|---|---|---|
| Curriculum | Contact | Materials | School 1 | School 2 | Mean | |
| 1 | Yes | No | No | 79 | 70 | 75 |
| 2 | Yes | Yes | No | 87 | 62 | 75 |
| 3 | Yes | No | Yes | 92 | 59 | 76 |
| 4 | Yes | Yes | Yes | 73 | 72 | 73 |
| 5 | No | No | No | 79 | 68 | 74 |
| 6 | No | Yes | No | 86 | 64 | 75 |
| 7 | No | No | Yes | 76 | 71 | 74 |
| 8 | No | Yes | Yes | 82 | 66 | 74 |
a
The eight top-ranked schools (school 1) were matched with the eight lowest ranked schools (school 2). Two schools withdrew for non–study-related reasons, and the study was repeated in a second academic year with a new set of sixth-grade students in five of the original schools, chosen because they had demographic characteristics similar to the lost schools. Thus a total of 19 classes from 14 schools were included in the study.
Participants and Procedures
A total of 751 students (60% of those invited) agreed to participate. Of these, 721 (96%) completed the study. Loss to follow-up (N=30) did not differ by gender, school, or socioeconomic status, but it did differ by race-ethnicity, with African American students dropping out at a higher rate, mostly due to moving. Sociodemographic characteristics of the 721 participants and their families are presented in Table 2.
| Characteristic | Total (N=751) | Curriculum (N=210, 28%) | Contact (N=218, 29%) | Curriculum and contact (N=135, 18%) | Contact (N=188, 25%) | |||||
|---|---|---|---|---|---|---|---|---|---|---|
| N | % | N | % | N | % | N | % | N | % | |
| Age (M±SD) | 12.0±.6 | 11.0±.6 | 12.0±.6 | 12.0±.6 | 12.0±.6 | |||||
| Female | 406 | 54 | 109 | 52 | 126 | 58 | 72 | 54 | 101 | 54 |
| Race-ethnicitya | ||||||||||
| Latino | 301 | 40 | 55 | 26 | 109 | 50 | 47 | 35 | 92 | 49 |
| White | 195 | 26 | 78 | 37 | 33 | 15 | 58 | 43 | 24 | 13 |
| Black | 180 | 24 | 52 | 25 | 50 | 23 | 24 | 18 | 51 | 27 |
| Other | 75 | 10 | 25 | 12 | 26 | 12 | 5 | 4 | 21 | 11 |
| English is primary language at homea | 526 | 70 | 162 | 77 | 137 | 63 | 107 | 79 | 117 | 62 |
| No contact with mental illness | 150 | 20 | 33 | 16 | 48 | 22 | 27 | 20 | 43 | 23 |
| Parent or guardian annual income <$50,000a | 518 | 69 | 120 | 57 | 172 | 79 | 81 | 60 | 145 | 77 |
| Parent or guardian education ≥12 yearsa | 631 | 84 | 191 | 91 | 172 | 79 | 118 | 88 | 152 | 81 |
a
p<.01, for differences between intervention groups
Pre- and posttest instruments were self-administered in physical education classes on laptop computers from February to May and September to December 2012. Each class received its assigned combination of interventions within one week of pretesting. Posttest instruments were administered within a week after the intervention. Informed consent of participants and their parents or guardians, following the Helsinki guidelines, was obtained after procedures were fully explained. All students in the classroom were exposed to the assigned intervention(s); only the students who provided consent completed the assessment instruments. The Columbia University Medical Center Institutional Review Board approved the study.
Interventions
Curriculum.
Eliminating the Stigma of Differences is a three-module, three-hour curriculum delivered by teachers over a three- to six-day period. PowerPoint slides provide a platform for classroom discussion. The teacher’s guide provides suggestions for questions to pose and information to convey to the class, as well as suggested in-class exercises and homework assignments. A demonstration video is also included. All materials were extensively pretested. Module 1 addresses the bases on which we judge others to be different; the definition, causes, and consequences of stigma, including for students themselves; ways to end stigma; a definition and description of mental illness; causes of mental illness; treatment for mental illness; barriers to help seeking; how stigma applies to mental illness; and sharing personal experiences with people who have mental illness. Modules 2 and 3 address attention-deficit hyperactivity disorder, anxiety disorders, depression, schizophrenia, and bipolar disorder and include descriptions of the disorders, discussion of causes and treatments, and content that stimulates empathy. Suicide is also discussed. The curriculum employs principles of active learning and the encouragement of empathy throughout.
Contact.
Two college students—a 27-year-old male with a history of bipolar I disorder and a 24-year-old female with a history of bipolar II disorder—each made a ten-minute in-class presentation (20 minutes total) describing onset and course of their symptoms, hospitalizations and treatments, their feelings about the illness, coping strategies, and impact of the illness on social relationships and functioning at school and work. Based on previous research (48), the talks were constructed to moderately disconfirm stereotypes of mental illness. The speakers practiced to ensure standardization of the presentations. Teachers moderated the presentations, which were followed by questions and answers.
Printed materials.
Teachers prominently displayed posters in the classroom for two weeks and provided students with bookmarks. The materials focused on individuals’ personal traits and abilities as opposed to language that labels a person as “mentally ill.” The curriculum and printed materials are accessible through the Web site of Mental Health Connection of Tarrant County (http://www.mentalhealthconnection.org/anti_stigma_materials.php).
Outcome Measures
Our primary goals were to reduce stigmatizing attitudes, beliefs, behaviors, and behavioral intentions and increase recognition of mental illnesses and favorable attitudes toward help seeking. We assembled a comprehensive assessment package utilizing existing measures with established psychometric properties for children and adolescents, measures extensively tested in adults that we adapted for adolescents, and new items developed for the study. We developed composite scales by using exploratory factor analysis. Internal consistency reliability of the scales was adequate to excellent for the overall sample and within gender, race-ethnicity, and socioeconomic-status groups. All measures were pilot-tested with a racially and ethnically diverse group of youths in the target age range. Measures were organized in terms of knowledge and attitudes, behavior and behavioral intentions, personal help-seeking attitudes, and vignette-based questions. Following a long tradition in stigma research (14,15,49), we created two vignettes. One vignette character (Julia) met DSM-IV criteria for bipolar disorder, and the other (David) met criteria for social anxiety disorder. Participants read the vignettes and responded to questions about Julia and David. Table 3 summarizes information about the outcome measures. [Tables in an online supplement to this article present wording of items, responses, vignettes, and pretest descriptive statistics for all items.]
| Measure | N items | Scoringa | Cronbach’s α | Sample item |
|---|---|---|---|---|
| Knowledge and attitudesb | 21 | 1, strongly agree, to 5, strongly disagree | .78 | It would be embarrassing to have a mental illness; people with a mental illness tend to be violent and dangerous. |
| Behavior and behavioral intentions | ||||
| Stigma awareness and actionc | 8 | 1, occurred in past 2 weeks; 0, did not | .67 | I heard people use slang terms about mental illness like “psycho,” “crazy,” or “looney” to put people down. |
| Avoidance and discomfortc | 6 | 1, occurred in past 2 weeks; 0, did not | .63 | I avoided a person who said odd things and behaved in strange ways. |
| Social distanceb | 6 | 1, definitely no, to 4, definitely yes | .89 | |
| Social distance subscale, less acceptable formsd | 3 | 1, definitely no, to 4, definitely yes | .81 | Would it be okay with you to work on a class project with someone with mental illness? |
| Social distance subscale, more acceptable formsd | 3 | 1, definitely no, to 4, definitely yes | .72 | Would it be okay with you to have someone with mental illness as a neighbor? |
| Personal willingness to seek help | 7 | 1, yes; 0, no | .78 | I would talk to my doctor if I were having a mental health problem. |
| Vignette based | ||||
| Beliefs about vignette characters and their mental health condition | 6 | 1, not at all likely, to 4, very likely | nae | Julia/David is in this situation because she/he is just a bad person. Julia/David is experiencing a mental illness. Julia’s/David’s situation will improve with treatment. |
| Social distance from vignette characters (combined overall score) | 8 | 1, definitely no, to 4, definitely yes | .92 | Would it be ok with you to live next door to Julia/David? |
| Vignette help-seeking recommendations | 12 | 1, yes; 0, no | .75 | Should Julia/David talk to a doctor about her/his problem? |
a
All scales are scored such that a higher score indicates more of the named construct.
b
Adapted from Wahl et al. (42)
c
Scales combine attitude/awareness and behavioral items.
d
The scale used to measure social distance was divided into more and less acceptable forms of contact on the basis of pre- and posttest means on social distance items. The overall scale was used as the primary outcome measure.
e
Analyzed as separate items
Other Variables
Personal contact with mental illness was assessed by a method used previously (32). Scores indicated the most intimate level of contact reported, from 0 (“I have never observed a person with mental illness”) to 7 (“I have a severe mental illness”). Social desirability bias was examined with a reliable scale for research on children (50,51). Fidelity to the curriculum content, quality of delivery, and level of student engagement were assessed by two observers in each classroom (intraclass correlation=.93) with a 60-item measure (available on request) based on two existing tools with good psychometric properties (52,53).
Statistical Analysis
Given the experimental design, personal characteristics could not cause self-selection into intervention groups. Nevertheless, it was possible for groups to differ at baseline because of imperfect randomization or differential participation. Significant pretest differences were found between intervention and control groups on race-ethnicity, primary language spoken at home, parent or guardian’s education and income, and level of contact with mental illness. We included pretest values of the corresponding outcome measures in the main analyses to control for preintervention group differences. We also reran our main analyses including the personal characteristics that differed at baseline and social desirability bias to determine whether they were significantly related to the outcomes after control for pretest values; they were not. Therefore, final analyses controlled only for pretest values of the outcomes.
Using analysis of covariance, we tested the effects of each intervention on the aforementioned outcomes. Across all analyses, outcomes for the printed-materials-only group did not differ significantly from the no-intervention control group. Combining the printed-materials-only group with the curriculum or contact intervention did not change the outcomes for the curriculum or contact group alone. Therefore, we combined the printed-materials-only group with the control group. Those receiving materials plus contact were grouped with the contact-only group and so forth. Our analyses thus compared outcomes for four groupings: curriculum only, contact only, curriculum plus contact, and control. The level of significance was set at .05.
Results
Fidelity to Curriculum Intervention
The mean fidelity score was 187. Possible scores range from 60 to 240, with scores of 148 to 192 considered “good” and scores of 193 to 240 “high fidelity.” We found no evidence of a linear effect of fidelity on the outcome measures, which we attributed to generally good fidelity and lack of substantial variance on the measure.
Outcome Analyses
Aside from correlations between the overall measure of social distance and its two subscales, there were no extremely high correlations between outcome measures, indicating that measures represented distinct aspects of stigma [see table in online supplement ]. The largest correlations were between knowledge and attitudes and social distance measures (–.56 to –.61) and between general and vignette-based social distance (.57 to .61). Other correlations ranged from nil to .40.
As shown in Table 4, intervention groups significantly differed from each other for ten of the 13 primary outcomes. In regard to the impact of specific interventions, we noted consistent patterns. The curriculum fairly consistently increased recognition of mental illness and positive orientations to help seeking, including stigma awareness and action, identification of the vignette characters as mentally ill rather than bad, endorsement of help seeking for the vignette characters and for oneself in a similar situation, and increased optimism about treatment effectiveness. The impact of the curriculum on social distance outcomes was weaker. Measures of avoidance and discomfort and social distance from the vignette characters and from “someone with a mental illness” did not differ significantly from those of the control group, although a subscale of the more acceptable forms of contact (be friends, be neighbors, or eat lunch together) showed significant improvement.
| Measure (possible score range)b | Curriculum | Contact | Curriculum and contact | Control | ||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Adjusted M | 95% CI | Adjusted M | 95% CI | Adjusted M | 95% CI | Adjusted M | 95% CI | Fc | dfd | |
| Knowledge and attitudes (1–5) | 3.60 | 3.55–3.65 | 3.54 | 3.49–3.59 | 3.66** | 3.60–3.72 | 3.53 | 3.48–3.58 | 4.33* | 3, 720 |
| Behavior and behavioral intentions | ||||||||||
| Stigma awareness and action (0–1) | .16** | .14–.18 | .12 | .10–.14 | .19*** | .16–.22 | .12 | .09–.14 | 6.42*** | 3, 716 |
| Avoidance and discomfort (0–1) | .06 | .05–.09 | .07 | .05–.09 | .07 | .04–.10 | .06 | .04–.08 | .19 | 3, 709 |
| Social distance (1–4) | 2.06 | 1.97–2.14 | 2.20 | 2.12–2.28 | 2.03 | 1.92–2.14 | 2.15 | 2.06–2.24 | 2.98* | 3, 716 |
| Subscale, less acceptable forms | 2.21 | 2.12–2.31 | 2.35 | 2.26–2.44 | 2.18 | 2.06–2.30 | 2.26 | 2.16–2.36 | 2.02 | 3, 717 |
| Subscale, more acceptable forms | 1.89* | 1.80–1.98 | 2.07 | 1.98–2.16 | 1.87* | 1.76–1.99 | 2.04 | 1.94–2.13 | 4.28** | 3, 716 |
| Would seek help (self) (0–1) | .68** | .64–.71 | .63 | .60–.67 | .71*** | .67–.70 | .60 | .56–.64 | 4.76** | 3, 707 |
| Vignette based | ||||||||||
| Julia is a bad person (1–4) | 1.70* | 1.60–1.80 | 1.81 | 1.71–1.91 | 1.65* | 1.52–1.78 | 1.85 | 1.75–1.96 | 2.53* | 3, 703 |
| Julia has a mental illness (1–4) | 3.15** | 3.05–3.25 | 3.16** | 3.07–3.26 | 3.29*** | 3.16–3.42 | 2.94 | 2.83–3.04 | 6.43*** | 3, 683 |
| Julia will improve with treatment (1–4) | 3.05* | 2.96–3.14 | 2.94 | 2.83–3.02 | 3.07* | 2.95–3.19 | 2.88 | 2.78–2.97 | 3.37* | 3, 684 |
| David is a bad person (1–4) | 1.73 | 1.64–1.83 | 1.83 | 1.74–1.93 | 1.68 | 1.56–1.81 | 1.75 | 1.64–1.85 | 1.36 | 3, 693 |
| David has a mental illness (1–4) | 2.81** | 2.70–2.92 | 2.81** | 2.70–2.92 | 2.83** | 2.69–2.97 | 2.58 | 2.46–2.70 | 3.88** | 3, 679 |
| David will improve with treatment (1–4) | 3.01*** | 2.91–3.12 | 2.73 | 2.63–2.84 | 2.99*** | 2.86–3.12 | 2.61 | 2.50–2.72 | 11.97*** | 3, 685 |
| Social distance from Julia and David (1–4) | 2.14 | 2.05–2.23 | 2.19 | 2.10–2.28 | 2.05 | 1.94–2.17 | 2.12 | 2.02–2.22 | 1.24 | 3, 686 |
| Julia and David should seek help (0–1) | .77** | .74–.80 | .77** | .74–.80 | .79** | .75–.83 | .71 | .67–.74 | 3.98** | 3, 707 |
a
All means were adjusted for the pretest value of the outcome measure. Adjusted means for intervention groups that were significantly different from the control group are indicated by asterisks (*p<.05, **p<.01, ***p<.001).
b
All scales are scored such that a higher score indicates more of the named construct.
c
Asterisks indicate whether the four groups were significantly different from each other (*p<.05, **p<.01, ***p<.001).
d
Values vary because of missing values on the outcome variable of interest.
The impact of contact was more limited. In the ten instances in which the overall effect of intervention was significant, the contact-only group differed significantly from the control group in only three instances—the belief that both vignette characters have a mental illness and that they should seek help. Adjusted means for curriculum only and curriculum plus contact did not differ significantly from each other, suggesting that in general contact did not add to the effect of the curriculum.
We also assessed interactions of gender, family income, race-ethnicity, and primary language spoken at home with the intervention. Of the 52 interactions tested, only five were significant (p<.05), and these failed to show any consistent pattern across outcomes (one for gender, one for income, one for race-ethnicity, and two for language).
Discussion and Conclusions
Stigma surrounding mental illness has proved difficult to change in the population. One promising approach may be to attack stigma at a young age, before negative attitudes become entrenched. However, research on interventions with preadolescents is limited. We conducted a school-based field experiment with sixth-grade students that evaluated an antistigma curriculum, an in-vivo contact intervention, and a social marketing strategy that saturated classrooms with informative messages. We evaluated the impact of the interventions on knowledge and attitudes about mental illness, behavior and behavioral intentions related to mental illness, and help-seeking attitudes.
Unfortunately, the simplest intervention to apply—saturating classrooms with antistigma written materials—had no significant impact on any outcomes. The contact intervention was less effective than the curriculum. The impact of the contact intervention was limited to increasing the tendency to identify the vignette conditions as mental illnesses that should be treated. This is at odds with studies of adults, which generally find that contact interventions are more effective than educational ones in reducing stigma (36). However, it is consistent with Corrigan and colleagues’ (36) meta-analysis, which showed that the opposite is true with adolescents. We located only one previous study with preadolescents that used a contact intervention (46). Although that study found reduced stigma after exposure to a lecture combined with personal contact, the predicted effects of varying the degree of stereotype disconfirmation embodied in the contact intervention were not observed. Also, because contact was combined in every case with a lecture, it is not clear whether stigma reduction resulted from contact. Although enthusiasm for contact interventions is justifiably strong, further evaluation of their effectiveness with young audiences is needed.
The curriculum was the most effective of the three interventions. It delivered a consistently beneficial impact on a diverse set of outcomes, tapping recognition of mental illness, awareness and action related to stigma, personal inclinations to seek help, and more favorable orientations toward the vignette characters and their prospects for improvement. However, the curriculum group did not differ significantly from the control group on avoidance and discomfort, the belief that David (with social anxiety disorder) is a bad person, and most social distance outcomes. The first two null findings may have been influenced by methodological factors: reported instances of avoidance and discomfort, assessed over a two-week period, as well as the belief that David is a bad person were very low for all experimental groups pre- and posttest. Our curriculum was less successful at reducing social distance than two previous studies that used preadolescent samples (42,45). It is not clear what accounts for the discrepant findings.
Some limitations should be noted. With any experimental study, recruitment bias can be problematic. Sixty percent of students invited decided to participate in our study. Some nonparticipating students or their families may hold particularly negative views about mental illness, possibly limiting the generalizability of our findings. For non–study-related reasons, two of the originally selected schools dropped out, which led us to return to five schools the following school year. We found no significant differences in participant characteristics between repeated and nonrepeated classrooms. Nevertheless, it is possible that the two lost classrooms differed from the remaining classrooms in terms of participant characteristics or response to the interventions. The results are also limited in that they include no long-term follow-up and rely on hypothetical rather than actual help seeking.
Our study makes several advances over previous ones, allowing greater confidence in the validity and generalizability of findings. There was no self-selection of teachers into the study or particular intervention conditions. Our fidelity measure, inclusion of which was another advance in the literature, showed that fidelity was generally high without self-selection or teacher training, suggesting that neither voluntary involvement nor previous training is necessary for high-quality implementation. The assessment of multiple interventions allowed us to attribute effects to particular interventions rather than to intervention per se and led us to conclude that the curriculum intervention was superior to the contact and printed-materials interventions. Our sample had excellent representation of the major U.S. racial and ethnic groups; thus we were able to show that interventions had a similar impact among Latino, African American, and non-Hispanic white youths. These study features raise optimism that stigma reduction interventions can generalize to a broad application in the population and strengthen existing evidence that even brief interventions can reduce stigma and may be transferrable to real-world applications. Future steps should include a direct comparison of curricula employed in the different intervention studies, perhaps combining elements that appear to most effectively address various components of stigma, and working with educators to begin to establish stigma reduction as part of the regular school curriculum.
Acknowledgments
The authors thank Mental Health Connection of Tarrant County, the project staff, the speakers who shared their experiences with mental illness, and the youths who participated in the study.
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References
1.
Corrigan P: How stigma interferes with mental health care. American Psychologist 59:614–625, 2004
2.
Corrigan P, Watson A, Barr L: The self-stigma of mental illness: implications for self-esteem and self-efficacy. Journal of Social and Clinical Psychology 25:875–884, 2006
3.
Druss BG, Bornemann TH: Improving health and health care for persons with serious mental illness: the window for US federal policy change. JAMA 303:1972–1973, 2010
4.
Link B, Castille DM, Stuber J: Stigma and coercion in the context of outpatient treatment for people with mental illnesses. Social Science and Medicine 67:409–419, 2008
5.
Link BG, Cullen FT, Struening E, et al: A modified labeling theory approach in the area of the mental disorders: an empirical assessment. American Sociological Review 54:400–423, 1989
6.
Link B: Understanding labeling effects in mental disorders: an assessment of expectations of rejection. American Sociological Review 52:96–112, 1987
7.
Link B, Struening E, Rahav M, et al: On stigma and its consequences: evidence from a longitudinal study of men with dual diagnoses of mental illness and substance abuse. Journal of Health and Social Behavior 38:117–190, 1997
8.
Perlick DA, Rosenheck RA, Clarkin JF, et al: Stigma as a barrier to recovery: adverse effects of perceived stigma on social adaptation of persons diagnosed with bipolar affective disorder. Psychiatric Services 52:1627–1632, 2001
9.
Perlick DA, Miklowitz DJ, Link BG, et al: Perceived stigma and depression among caregivers of patients with bipolar disorder. British Journal of Psychiatry 190:535–536, 2007
10.
Rosenfield S: Labeling mental illness: the effects of received services and perceived stigma on life satisfaction. American Sociological Review 62:660–672, 1997
11.
Sirey JA, Bruce ML, Alexopoulos GS, et al: Perceived stigma as a predictor of treatment discontinuation in young and older outpatients with depression. American Journal of Psychiatry 158:479–481, 2001
12.
Wahl OF: Stigma as a barrier to recovery from mental illness. Trends in Cognitive Sciences 16:9–10, 2012
13.
Wright ER, Gronfein WP, Owens TJ: Deinstitutionalization, social rejection, and the self-esteem of former mental patients. Journal of Health and Social Behavior 41:68–90, 2000
14.
Pescosolido BA, Jensen PS, Martin JK, et al: Public knowledge and assessment of child mental health problems: findings from the National Stigma Study–Children. Journal of the American Academy of Child and Adolescent Psychiatry 47:339–349, 2008
15.
Link BG, Phelan JC, Bresnahan M, et al: Public conceptions of mental illness: labels, causes, dangerousness, and social distance. American Journal of Public Health 89:1328–1333, 1999
16.
Sartorius N: Fighting schizophrenia and its stigma: a new World Psychiatric Association educational programme. British Journal of Psychiatry 170:297, 1997
17.
Hinshaw SP: The Mark of Shame: Stigma of Mental Illness and an Agenda for Change. Oxford, United Kingdom, Oxford University Press, 2006
18.
Dumesnil H, Verger P: Public awareness campaigns about depression and suicide: a review. Psychiatric Services 60:1203–1213, 2009
19.
Pilgrim D, Rogers AE: Psychiatrists as social engineers: a study of an anti-stigma campaign. Social Science and Medicine 61:2546–2556, 2005
20.
Schomerus G, Schwahn C, Holzinger A, et al: Evolution of public attitudes about mental illness: a systematic review and meta-analysis. Acta Psychiatrica Scandinavica 125:440–452, 2012
21.
Pescosolido BA, Martin JK, Long JS, et al: “A disease like any other”? A decade of change in public reactions to schizophrenia, depression, and alcohol dependence. American Journal of Psychiatry 167:1321–1330, 2010
22.
Angermeyer MC, Matschinger H: Have there been any changes in the public’s attitudes towards psychiatric treatment? Results from representative population surveys in Germany in the years 1990 and 2001. Acta Psychiatrica Scandinavica 111:68–73, 2005
23.
Mackenzie CS, Erickson J, Deane FP, et al: Changes in attitudes toward seeking mental health services: a 40-year cross-temporal meta-analysis. Clinical Psychology Review 34:99–106, 2014
24.
Phelan JC, Link BG, Stueve A, et al: Public conceptions of mental illness in 1950 and 1996: what is mental illness and is it to be feared? Journal of Health and Social Behavior 41:188–207, 2000
25.
Phelan JC: Geneticization of deviant behavior and consequences for stigma: the case of mental illness. Journal of Health and Social Behavior 46:307–322, 2005
26.
Kvaale EP, Haslam N, Gottdiener WH: The “side effects” of medicalization: a meta-analytic review of how biogenetic explanations affect stigma. Clinical Psychology Review 33:782–794, 2013
27.
Kvaale EP, Gottdiener WH, Haslam N: Biogenetic explanations and stigma: a meta-analytic review of associations among laypeople. Social Science and Medicine 96:95–103, 2013
28.
Wahl O: Children’s views of mental illness: a review of the literature. Psychiatric Rehabilitation Skills 6:134–158, 2002
29.
Corrigan PW, Watson AC: How children stigmatize people with mental illness. International Journal of Social Psychiatry 53:526–546, 2007
30.
Chandra A, Minkovitz C: Factors that influence mental health stigma among 8th grade adolescents. Journal of Youth and Adolescence 6:763–774, 2007
31.
Adler A, Wahl O: Children’s beliefs about people labeled mentally ill. American Journal of Orthopsychiatry 68:321–326, 1998
32.
Corrigan PW, Green A, Lundin R, et al: Familiarity with and social distance from people who have serious mental illness. Psychiatric Services 52:953–958, 2001
33.
Shah N: Changing minds at the earliest opportunity. Psychiatric Bulletin 28:213–215, 2004
34.
Weiss MF: Children’s attitudes toward the mentally ill: a developmental analysis. Psychological Reports 58:11–20, 1986
35.
Weiss MF: Children’s attitudes toward mental illness as assessed by the Opinions About Mental Illness Scale. Psychological Reports 57:251–258, 1985
36.
Corrigan PW, Morris SB, Michaels PJ, et al: Challenging the public stigma of mental illness: a meta-analysis of outcome studies. Psychiatric Services 63:963–973, 2012
37.
Couture SM, Penn DL: Interpersonal contact and the stigma of mental illness: a review of the literature. Journal of Mental Health 12:291–305, 2003
38.
Holzinger A, Dietrich S, Heitmann S, et al: Evaluation of target-group oriented interventions aimed at reducing the stigma surrounding mental illness [in German]. Psychiatrische Praxis 35:376–386, 2008
39.
Mellor C: School-based interventions targeting stigma of mental illness: systematic review. Psychiatric Bulletin 38:164–171, 2014
40.
Evans-Lacko S, London J, Japhet S, et al: Mass social contact interventions and their effect on mental health related stigma and intended discrimination. Public Health 12:489, 2012
41.
Watson AC, Otey E, Westbrook AL, et al: Changing middle schoolers’ attitudes about mental illness through education. Schizophrenia Bulletin 30:563–572, 2004
42.
Wahl OF, Susin J, Kaplan L, et al: Changing knowledge and attitudes with a middle school mental health education curriculum. Stigma Research and Action 1:44–53, 2011
43.
Desocio J, Stember L, Schrinsky J: Teaching children about mental health and illness: a school nurse health education program. Journal of School Nursing 22:81–86, 2006
44.
Pietre N, Stewart S, Adams S, et al: The use of puppets with elementary school children in reducing stigmatizing attitudes toward mental illness. Journal of Mental Health 16:415–429, 2007
45.
Ventieri D, Clarke DM, Hay M: The effects of a school-based educational intervention on preadolescents’ knowledge of and attitudes toward mental illness. Advances in School Mental Health Promotion 4:5–17, 2011
46.
Spagnolo AB: Examining the effects of anti-stigma messages on the attitudes of early adolescents. Doctoral dissertation. Newark, Department of Psychology, University of Medicine and Dentistry of New Jersey, 2009
47.
Dixon S, Stein M: Encounters with Children: Pediatric Behavior and Development, 3rd ed. St Louis, Mosby, 2000
48.
Reinke R, Corrigan P, Leonhard C, et al: Examining two aspects of contact on the stigma of mental illness. Journal of Social and Clinical Psychology 23:377–389, 2004
49.
Star S: The public’s ideas about mental illness. Presented at the Annual Meeting of the National Association for Mental Health, Indianapolis, Nov 5, 1955
50.
Baxter SD, Smith AF, Litaker MS, et al: Children’s social desirability and dietary reports. Journal of Nutrition Education and Behavior 36:84–89, 2004
51.
Crandall VC, Crandall VJ, Katkovsky W: A children’s social desirability questionnaire. Journal of Consulting Psychology 29:27–36, 1965
52.
Dusenbury L, Brannigan R, Falco M, et al: A review of research on fidelity of implementation: implications for drug abuse prevention in school settings. Health Education. Research Theory and Practice 18:237–256, 2003
53.
Bruns EJ, Burchard JD, Suter JC, et al: Assessing fidelity to a community-based treatment for youth: the wraparound fidelity index. Journal of Emotional and Behavioral Disorders 12:79–89, 2004
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Cover: Freeway and Aqueduct, by Richard Diebenkorn, 1957. Oil on canvas. Gift of William and Regina Fadiman (M.86.68). Los Angeles County Museum of Art, Los Angeles. Digital image © 2017 Museum Associates/LACMA, Licensed by Art Resource, New York City.
History
Received: 29 January 2016
Revision received: 10 July 2016
Accepted: 16 August 2016
Published online: 15 November 2016
Published in print: April 01, 2017
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Competing Interests
The authors report no financial relationships with commercial interests.
Funding Information
National Institute of Mental Health10.13039/100000025: R01MH095254
The study was supported in part by grants R01MH095254 and 5T32MH013043-44 from the National Institute of Mental Health.Metrics & Citations
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