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www. mind.org.hk

Case Study

Report

Anti-stigma Campaigns Globally

June 2020

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Table of Contents Introduction 3

Anti-stigma campaigns 4

The Case of Mental Health and Mental Health Stigma in Hong Kong 5

Attitudes toward Mental Health: Mind HK’s Stigma Research (2018) 6

The Case of Mental Health and Mental Health Stigma in Hong Kong 7

Case Study 1: Time to Change (TTC) - UK 8 BACKGROUND 8 IMPACT AND EVALUATION 9

Case Study 2: Opening Minds (OM) - Canada 11 BACKGROUND 11 IMPACT AND EVALUATION 12

Case Study 3: Beyond Blue - Australia 13 BACKGROUND 13 IMPACT AND EVALUATION 14

Case Study 4: Like Minds, Like Mine (LMLM) - New Zealand 15 BACKGROUND 15 IMPACT AND EVALUATION 16

Case Study 5: Beyond the Label (BTL) - Singapore 16 BACKGROUND 16 IMPACT AND EVALUATION 17

Case Study 6: SMART - India 17 BACKGROUND 17 IMPACT AND EVALUATION 17

Discussion 18

Recommendations 19

Conclusion 20

Appendix: 21

TTC additional details: 21 References: 22

About Mind HK 23

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Introduction

Stigma, defined as a mark of disgrace associated with a particular circumstance,

quality, or person, has a detrimental impact on mental health . The overwhelmingly 1

negative portrayal of mental health impairs self-esteem, promotes self-stigma, delays help-seeking and undermines recovery . Changing attitudes, addressing the language, 2

and raising awareness through anti-stigma campaigns is a powerful public health tool for improving the mental well-being of all. With mental health problems on the rise and stigma prevalent across backgrounds, several successful anti-stigma campaigns have been implemented worldwide over the last decade. This case study report seeks to review and evaluate some of the most renowned anti-stigma campaigns, to inform and recommend stigma-reduction interventions that can be localised and implemented within the context of Hong Kong.

Globally, one in four of us will experience a mental health problem in our lifetime, yet more than 70% of people with a mental illness receive no treatment from a health care professional . This is no different in Hong Kong, with only 26% of people with mental 3

health problems seeking help from professionals . While the reasons for the treatment 4

gap are complex, the stigma and discrimination surrounding mental health play a significant and powerful role. Stigma influences attitudes and behaviors of individuals and communities, shaping the wellbeing of mental health sufferers, as well as relevant legislation, funding and availability of health-care services . 5

1 “Stigma | Meaning of Stigma in English”. (2020). Lexico Dictionaries | English . Retrieved from https://www.lexico.com/definition/stigma 2 Stuart, H., et al. (2014). Opening Minds in Canada: Background and Rationale. The Canadian Journal of Psychiatry , 59(1), 8–12. DOI:10.1177/070674371405901S04. 3 Henderson, C., et al. (2013). Mental Illness Stigma, Help Seeking, and Public Health Programs. American Journal of Public Health , 103(5), 777. DOI:10.2105/AJPH.2012.301056. 4 Food and Health Bureau, Hong Kong Special Administrative Region Government. (2017, March). Mental Health Review Report. Retrieved from https://www.fhb.gov.hk/download/press_and_publications/otherinfo/180500_mhr/e_mhr_full_report.pdf 5 Henderson, C., et al. (2013). Mental Illness Stigma, Help Seeking, and Public Health Programs. American Journal of Public Health, 103(5), 777. DOI:10.2105/AJPH.2012.301056.

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Anti-stigma campaigns

Anti-stigma campaigns are collectives that work together to address the stigma

surrounding mental health. While anti-stigma campaigns are typically carried out on a national level, they can also be carried out on a global or local level. Currently, the Western Hemisphere is leading the fight against the stigmatisation of mental health. As of July 2019, the most prominent campaigns include: Time to Change (UK), Opening Minds (Canada) and Beyond Blue (Australia).

Just as the impact of stigma on mental health is wide-ranging, so are the approaches to combat mental health stigma. Each anti-stigma campaign is comprised of multiple components that tackle specific target groups . Examples of these approaches 6

include: education, contact, protest, advocacy, and policy change . These different 7

approaches, combined with the awareness of anti-stigma campaigns, can lead to greater disclosure of mental health issues and increase the likelihood of prevention and early intervention . Additionally, anti-stigma campaigns and the specific use of contact 8

intervention) can help eliminate self-stigma and boost self-esteem and empowerment, leading to an increase in the prevalence of help-seeking and a narrowed treatment gap . 9

6 Henderson, C., et al. (2013). Mental Illness Stigma, Help Seeking, and Public Health Programs. American Journal of Public Health , 103(5), 777. DOI:10.2105/AJPH.2012.301056 7 Committee on the Science of Changing Behavioral Health Social Norms, et al. (2016). Approaches to Reducing Stigma. In Committee on the Science of Changing Behavioral Health Social Norms, et al. (Eds.). Ending Discrimination Against People with Mental and Substance Use Disorders. Washington (DC): National Academies Press (US) Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK384914/ 8 Henderson, C., et al. (2013). Mental Illness Stigma, Help Seeking, and Public Health Programs. American Journal of Public Health , 103(5), 777. DOI:10.2105/AJPH.2012.301056 9 Committee on the Science of Changing Behavioral Health Social Norms, et al. (2016). Approaches to Reducing Stigma. In Committee on the Science of Changing Behavioral Health Social Norms, et al. (Eds.). Ending Discrimination Against People with Mental and Substance Use Disorders. Washington (DC): National Academies Press (US) Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK384914/

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The Case of Mental Health and Mental

Health Stigma in Hong Kong

An estimated one in seven Hong Kongers suffers from mental health problems . 10

Additionally, one in four workers show symptoms of depression and anxiety, which is more than double the global average. Despite the prevalence of mental health issues in Hong Kong, the stigma surrounding mental health has resulted in both a lack of resources and a suppression of help-seeking behaviour by those affected.

Hong Kong has only one clinical psychologist for every 18,000 Hong Kongers, a ratio which is less than half of the WHO’s recommendation . As for psychiatrists, the 11

recommended number is at least one for every 10,000 people which would equate to a minimum of 700 for Hong Kong - currently, Hong Kong has only 345 psychiatrists. Even when help is provided, appointments are short, with follow up appointments for psychiatric patients frequently lasting less than eight minutes, according to a spokesman for the Hong Kong College of Psychiatrist.

In addition to the stark lack of mental health resources available, stigma and negative attitudes towards mental health have resulted in low outreach for help, where only 26% of those experiencing a mental health problem in Hong Kong seek help . This 12

figure illustrates the impact mental health stigma, in Hong Kong, has on help-seeking behavior and mental well-being; something stakeholders from all walks of life are urged to tackle.

10 Lam, L.C., Wong, C.S., Wang, M.J., et al. (2015). Prevalence, psychosocial correlates and service utilisation of depressive and anxiety disorders in Hong Kong: the Hong Kong Mental Morbidity Survey. Soc Psychiatry Psychiatr Epidemiol. 50, 1379–1388. DOI: 10.1007/s00127-015-1014-5 11 Tien, L. (2017). United States Model of Training Doctoral Level Clinical Psychologists. Retrieved from https://www.legco.gov.hk/yr17-18/english/panels/hs/papers/hscb2-174-1-e.pdf 12 Henderson, C., et al. (2013). Mental Illness Stigma, Help Seeking, and Public Health Programs. American Journal of Public Health , 103(5), 777. DOI:10.2105/AJPH.2012.301056

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Attitudes toward Mental Health: Mind

HK’s Stigma Research (2018)

In 2018, Mind HK conducted a city-wide study on the mental health stigma and

attitude within Hong Kong. The purpose of this study was two-fold: 1) to gain a better understanding of mental health in the Hong Kong context and environment and 2) to understand how to target successful, future mental health awareness-raising and anti-stigma campaigns . 13

The study involved a random sample of 1210 participants. Methods utilised were modified and adapted from the UK’s 2007 anti-stigma campaign, Time to Change. The research was completed in partnership with the University of Hong Kong, Time to Change UK and King's College London.

The research indicates that there is a clear misunderstanding of what constitutes a mental illness. Over 50% of participants agreed that stress is a mental illness, while only 24% of participants were able to correctly identify drug addiction as a mental illness . 14

With regards to the CAMI psychometric scale, respondents expressed hope for increased tolerance surrounding mental health in theory, but their intended behaviours indicated otherwise. 89% of participants agreed that Hong Kong needs to adopt a more tolerant attitude towards those with mental illnesses, and 87% agreed that ‘virtually anyone can become mentally ill’ . However, 30% of respondents expressed hesitations to 15

living next door to someone who has been mentally ill, and a similar 27% felt it would be ‘frightening to think of people with mental health problems living in their residential neighbourhoods’ . 16

41% of respondents agreed the main cause of mental illness is a lack of self-discipline and will-power; a clear sign of misunderstanding and lack of awareness . 17

60% of respondents did not know where to access help outside of hospitals, and only 39% of respondents had heard of anti-stigma campaigns . These statistics highlight that 18

13 Mind HK. (2018). Mental Health related knowledge, attitudes and behaviors in the general population in Hong Kong. 14 Mind HK. (2018). Mental Health related knowledge, attitudes and behaviors in the general population in Hong Kong. p.10. 15 Mind HK. (2018). Mental Health related knowledge, attitudes and behaviors in the general population in Hong Kong. p.12. 16 Mind HK. (2018). Mental Health related knowledge, attitudes and behaviors in the general population in Hong Kong. p.12. 17 Mind HK. (2018). Mental Health related knowledge, attitudes and behaviors in the general population in Hong Kong. p.12. 18 Mind HK. (2018). Mental Health related knowledge, attitudes and behaviors in the general population in Hong Kong. p.20.

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there is a clear need for a well-developed, local anti-stigma campaign to reduce mental health stigma, increase knowledge levels, and improve access to care in Hong Kong.

The Case of Mental Health and Mental

Health Stigma in Hong Kong

For this report, six anti-stigma campaigns have been analysed and evaluated to

gain a greater picture of the efficacy of anti-stigma campaigns globally. Additionally, suggestions have been made on how these approaches could be applied to the Hong Kong context in the hopes of a stigma-free future for Hong Kong. The six case studies examined will be: Time to Change (England); Opening Minds (Canada); Beyond Blue (Australia); Like Minds, Like Mine (New Zealand); Beyond the Label (Singapore); and SMART (India).

Case Study 1: Time to Change (TTC) - UK BACKGROUND

Time to Change (TTC) is a mental health campaign that was launched in 2007 in England. The campaign aims to change the way we think and act about mental health problems. It also hopes to stress the importance of mental health for all, as one in four of us will experience a mental health problem in any given year . Their campaign slogan is: 19

“Let’s end mental health discrimination”.

To help end mental health discrimination, TTC’s focus is split into four areas: 1) changing attitudes in the workplace, 2) changing attitudes of children and young people, 3) changing attitudes in communities and 4) campaigns . Within these four areas, 20

comprehensive open-resources and activities have been created for public use (See Appendix 1).

In addition to TTC UK, TTC Global, which focuses on establishing anti-stigma campaigns in developing countries, will be rolling out anti-stigma campaigns in both Asia and Africa in partnership with local organisations in their respective regions. Their expanded global work is funded by the UK government and Comic Relief, delivered in partnership with Christian Blind Mission UK (CBM UK). Apart from aiming to improve attitudes surrounding mental health and reduce stigma, the primary focus of TTC Global

19 “About Us”. (2018, July 16). Time To Change . Retrieved from https://www.time-to-change.org.uk/about-us 20 “What We Do”. (2018, July 16). Time To Change . Retrieved from https://www.time-to-change.org.uk/about-us/what-we-do

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is to create a sustainable long-term global campaign . TTC is a part of the Global 21

Anti-Stigma Alliance (GASA), a global network of well-established organisations partnering to reduce stigma surrounding mental health. GASA is composed of members from over 17 countries, including Mind HK . 22

Campaigns are a core component of TTC’s work; partnerships with high-profile brands (e.g. Ford Motor Company) increase the reach of their work and further campaign impact. Currently, TTC runs two national campaigns: ‘Time To Talk Day’ and ‘In Your Corner’. ‘Time to Talk Day’ is an annual anti-stigma campaign geared towards opening a conversation about mental health. ‘In Your Corner’ is a five-year campaign, which started in 2017, targeting men and young people . 23

Current campaigns reflect the goals of TTC. TTC is in its third phase of operation, running from 2016 to 2021. This phase aims to engage with those who do not view mental health as relevant to themselves, with a focus on men and young people . 24

Although TTC reported, in 2016, that 4.1 million people already have improved attitudes towards mental health, there is still a persistent gap between men and women, with men showing less favorable attitudes towards mental health . In Your Corner encourages 25

men and young people to step in if their close peers are experiencing a mental health problem. As part of this campaign, ‘Ask Twice’ was introduced. This campaign encourages people to double-check on their friends - based on the statistic that when asked, 78% of participants would say they were fine, even if they were struggling with a mental health issue . Their campaign strategies underline the need to evaluate gaps in 26

the system and attitudes within population groups, to assess and design relevant campaigns.

IMPACT AND EVALUATION

TTC has delivered a positive impact on reducing mental health discrimination in the UK and is one of the most evidence-based anti-stigma campaigns globally. In internal impact evaluations, TTC acknowledges that their sole impact cannot be fully isolated, due to the presence and work of other campaigns within the country; all

21 “Our Global Work: What We Do”. (2018, Sept 3). Time To Change . Retrieved from https://www.time-to-change.org.uk/about-us/what-we-do/our-global-work/our-global-work-what-we-do 22 “Our Global Work: What We Do”. (2018, Sept 3). Time To Change . Retrieved from https://www.time-to-change.org.uk/about-us/what-we-do/our-global-work/our-global-work-what-we-do 23 “Our Latest Campaign”. (2017, Feb 22). Time To Change . Retrieved from https://www.time-to-change.org.uk/media-centre/our-latest-campaign 24 Time To Change. (2019). Our Impact. 2018/2019. Retrieved from https://www.time-to-change.org.uk/sites/default/files/TTC_Impact%20Report%20_FINAL%20VERSION.pdf 25 “Our Latest Campaign”. (2017, Feb 22). Time To Change . Retrieved from https://www.time-to-change.org.uk/media-centre/our-latest-campaign 26 “Ask Twice, People Urged, as New Research Shows Three Quarters of Brits Would Say They Are ‘Fine’ Even If Struggling with a Mental Health Problem”. (2018, Oct 3). Time To Change . Retrieved from https://www.time-to-change.org.uk/news/ask-twice-people-urged-new-research-shows-three-quarters-brits-would-say-they-are-%E2%80%98fine%E2%80%99-even

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working towards a collective societal shift away from mental health stigma and discrimination . 27

In a report published by King’s College London in 2016, the impact of TTC on public attitudes, social contact and reported distance with mental health problems was analysed. Using the MAKS psychometric scale, respondents experienced significant improvement in overall mental health knowledge in 2014 and 2015 compared to 2009, which shows a direct increase in public knowledge and awareness. Public attitudes also showed significant improvement, with scores in 2015 being 0.20 standard deviations higher than that in 2008 . Although, overall, there was improvement in public attitudes, 28

this impact varied between age groups, with the eldest groups showing the least change in attitude over time . Different age groups respond differently to anti-stigma campaigns 29

and it may be more challenging to change attitudes of older populations. This might suggest greater benefits in directing the campaign towards a younger population, or developing different campaign models according to age group.

TTC has achieved a positive impact on mental health attitudes, already reaching an additional 3.1% improvement by 2019, towards its target of 5% by 2021 . In their most 30

recent impact report, TTC collected data on changes in attitudes towards mental health. When comparing data from previous evaluations of TTC impact in 2016/2017 and 2018/2019, attitudes among the adult population were seen to improve by a further 3.1% above the baseline improvement of 9.6%, giving a total improvement of 12.7% since the project began. This corresponds to an additional 1.3 million individuals, increasing the number of people with improved attitudes from the 2016 figure of 4.1 million to 5.4 million.

Case Study 2: Opening Minds (OM) - Canada BACKGROUND

Established in 2009 by the Mental Health Commission of Canada (MHCC), Opening Minds (OM) is the largest systematic effort in Canada focused on reducing mental health stigma. They seek to change attitudes and behaviors towards people

27 Time To Change. (2019). Our Impact. 2018/2019. Retrieved from https://www.time-to-change.org.uk/sites/default/files/TTC_Impact%20Report%20_FINAL%20VERSION.pdf 28 Henderson, C., et al. (2016). Public Knowledge, Attitudes, Social Distance and Reported Contact Regarding People with Mental Illness 2009–2015. Acta Psychiatrica Scandinavica , 134(S446), 23-33. DOI:10.1111/acps.12607 29 Henderson, C., et al. (2016). Public Knowledge, Attitudes, Social Distance and Reported Contact Regarding People with Mental Illness 2009–2015. Acta Psychiatrica Scandinavica , 134(S446), 23-33. DOI:10.1111/acps.12607 30 Time To Change. (2019). Our Impact. 2018/2019. Retrieved from https://www.time-to-change.org.uk/sites/default/files/TTC_Impact%20Report%20_FINAL%20VERSION.pdf

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living with a mental illness to ensure they are treated fairly and given the same opportunities as anyone else. Their ultimate goal is to cultivate an environment in which those affected by mental health feel comfortable seeking help, treatment and support on their journey towards recovery . OM has four main target groups: youth, the 31

workforce, health care providers and the media . 32

Initially, OM launched its initiative through a media and marketing campaign , but ultimately discovered that a grass-roots approach would be more cost-effective and sustainable for the future. To keep their approaches relevant, they have assigned principal academic investigators to each target group to identify, document and disseminate the leading practices in stigma reduction . This has allowed accurate 33

evaluation and assessment of intervention efforts among target groups, to assess whether or not they are successful and if changes could be sustained . These measures 34

varied for each target group.

To address the stigma of mental health with youth, OM has developed the MHCC Youth Council and the HEADSTRONG initiative. The MHCC Youth Council aims to allow young adults, aged 18-30, to have hands-on involvement in youth intervention efforts to reduce stigma. Programmes that they have worked on include video creation and editing OM resources to make them more youth-friendly . MHCC HEADSTRONG, an initiative 35

developed in 2014, works closely with community organisations, schools and youth to raise mental health awareness and reduce stigma among youth. National and regional anti-stigma youth summits are one of the main ways they have done this . To make the 36

regional summits effective, extensive toolkits and resources are provided to organisers, including: how to plan a summit, speaker training, sharing personal stories and sample school-based activities . 37

The workforce is another major area OM is working to reduce stigma within. OM has introduced the National Standard of Canada for Psychological Health and Safety in the Workplace (simply known as the Standard). This is a voluntary set of guidelines and resources that outlines how to promote mental health in the workplace. A similar standard is provided for health care providers, who are encouraged to sign a declaration of commitment to psychological health and safety in healthcare . Further training 38

31 “Opening Minds”. (2019, July 19). Mental Health Commission of Canada . Retrieved from https://www.mentalhealthcommission.ca/English/opening-minds 32 “Opening Minds” . (2019, July 19). Mental Health Commission of Canada . Retrieved from https://www.mentalhealthcommission.ca/English/opening-minds 33 Pietrus, M. (2013). Opening Minds Interim Report . Calgary: Mental Health Commission of Canada. p. 3. 34 Pietrus, M. (2013). Opening Minds Interim Report . Calgary: Mental Health Commission of Canada. p. 3. 35 “MHCC Youth Council”. (2020, Jun 22). Mental Health Commission of Canada . Retrieved from https://www.mentalhealthcommission.ca/English/who-we-are/mhcc-networks/mhcc-youth-council 36 Mental Health Commission of Canada. (2016). The Mental Health Commission of Canada’s HEADSTRONG Youth Anti-Stigma Initiative: 2014-2015 Final Report . p. 7. Retrieved from: http://www.deslibris.ca/ID/10050330 37 Mental Health Commission of Canada. (2016). The Mental Health Commission of Canada’s HEADSTRONG Youth Anti-Stigma Initiative: 2014-2015 Final Report . p. 8. Retrieved from: http://www.deslibris.ca/ID/10050330 38 “Workplace”. (2020, June 22). Mental Health Commission of Canada . Retrieved from https://www.mentalhealthcommission.ca/English/what-we-do/workplace

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resources such as Mental Health First Aid and The Working Mind are provided to support both employers and employees . 39


To gauge the effectiveness of the HEADSTRONG regional campaigns, a research team collected different forms of data, including participation data, fidelity to the programme, regional coordinator reports and student surveys. The impact of the HEADSTRONG campaign on reducing stigma was assessed by surveying the opinions of student participants about people with mental health conditions. Students were surveyed before and after participating in the programme. Comparing the before and after results, shows a change in attitude towards mental health, with an almost 20% increase in the number of students who had “non-stigmatising attitudes”. The surveys also suggest that students became more tolerant of people with mental health issues. The number of students whose answers to questions regarding the social acceptance of people with mental illness were “non-stigmatising” increased by 13.2% after the programme . Another aspect that appeared to have a large impact on results was 40

fidelity to the programme. In general, regional summits that demonstrated higher fidelity to the speaker training and programme at large saw a higher percentage of positive change in “non-stigmatising” attitudes . 41

Case Study 3: Beyond Blue - Australia BACKGROUND

Currently, three million Australians experience anxiety or depression, and eight people take their own lives each day . Beyond Blue is an Australian based NGO that 42

works to address issues associated with suicide, depression and other related mental health issues. Their vision is for everyone in Australia to achieve their best possible mental health. Their values are collaboration, respect, enthusiasm, excellence, innovation and integrity. Their main aims are to: 1) reduce the impact of anxiety, depression and suicide by supporting people and encouraging recovery, 2) reduce people’s experiences

39 “Workplace”. (2020, June 22). Mental Health Commission of Canada . Retrieved from https://www.mentalhealthcommission.ca/English/what-we-do/workplace 40 Mental Health Commission of Canada. (2016). The Mental Health Commission of Canada’s HEADSTRONG Youth Anti-Stigma Initiative: 2014-2015 Final Report . p. 24. Retrieved from: http://www.deslibris.ca/ID/10050330 41 Mental Health Commission of Canada. (2016). The Mental Health Commission of Canada’s HEADSTRONG Youth Anti-Stigma Initiative: 2014-2015 Final Report . p. 25. Retrieved from: http://www.deslibris.ca/ID/10050330 42 “Who We Are and What We Do”. (2020, June 22). BeyondBlue. Retrieved from https://www.beyondblue.org.au/about-us/who-we-are-and-what-we-do

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of stigma and depression, 3) improve the opportunity to get effective support and services when needed and 4) use best practices to deliver integrated, evidence-based and cost-effective initiatives . 43

Beyond Blue aims to target all parts of Australia, whether it be at home, work, school or online. BlueVoices is Beyond Blue’s online community, that allows the sharing of experiences by those with lived experiences and provides a community in which those who are suffering from anxiety, depression or suicidal thoughts can find support . 44

Participants of BlueVoices were then invited to participate in Beyond Blue events, such as the ‘Know When Anxiety Is Talking’ campaign and suicide prevention research . 45

NewAccess, an early intervention programme, was also developed by Beyond Blue . NewAccess is a free and confidential service that provides users with coaches to 46

help them create practical strategies and solutions to daily challenges without a medical referral and for up to five weekly thirty-minute sessions . 47

Apart from early intervention programmes, Beyond Blue also provides recovery resources including: The Way Back Support Service and BeyondNow. The Way Back Support Service is a three-month support service for people who have attempted suicide or are experiencing a suicidal crisis . Individuals typically utilise this service 48

during the hospital discharge process. BeyondNow is an app designed to help people manage their suicidal thoughts and feelings . Beyond services, ambassadors and 49

community events are a great way to invite the community to be a part of this conversation. These activities and events include the Tough Mudder Race AFL Victoria Beyond Blue Round and large scale concerts such as Ed Sheeran’s national tour, for which Beyond Blue was the primary charity . 50

43 “Who We Are and What We Do”. (2020, June 22). BeyondBlue. Retrieved from https://www.beyondblue.org.au/about-us/who-we-are-and-what-we-do 44 BeyondBlue. (2018). Annual Highlights 2017-2018. Retrieved from https://www.beyondblue.org.au/docs/default-source/default-document-library/bl1890_annual_highlights_web.pdf?sfvrsn=15dda8ea_2 45 BeyondBlue. (2018). Annual Highlights 2017-2018. Retrieved from https://www.beyondblue.org.au/docs/default-source/default-document-library/bl1890_annual_highlights_web.pdf?sfvrsn=15dda8ea_2 46 BeyondBlue. (2018). Annual Highlights 2017-2018. p.10. Retrieved from https://www.beyondblue.org.au/docs/default-source/default-document-library/bl1890_annual_highlights_web.pdf?sfvrsn=15dda8ea_2 47 Beyond Blue. (2020, June 22). NewAccess – FAQs. Retrieved from https://www.beyondblue.org.au/get-support/newaccess/faqs 48 BeyondBlue. (2018). Annual Highlights 2017-2018. p.11. Retrieved from https://www.beyondblue.org.au/docs/default-source/default-document-library/bl1890_annual_highlights_web.pdf?sfvrsn=15dda8ea_2 49 BeyondBlue. (2018). Annual Highlights 2017-2018. p.11. Retrieved from https://www.beyondblue.org.au/docs/default-source/default-document-library/bl1890_annual_highlights_web.pdf?sfvrsn=15dda8ea_2 50 BeyondBlue. (2018). Annual Highlights 2017-2018. p.22. Retrieved from https://www.beyondblue.org.au/docs/default-source/default-document-library/bl1890_annual_highlights_web.pdf?sfvrsn=15dda8ea_2

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Beyond Blue’s early intervention campaign NewAccess has had a lot of success, including a 60-70% recovery rate and a reach of over six thousand people in Australia . 51

As a whole, Beyond Blue has extremely high brand recognition and is the organisation most commonly associated with mental health in Australia. This high level of recognition is predominantly due to their campaigns, social media presence and the activities and influence of their CEO . High visibility and recognition have helped to facilitate the 52

increase of help-seeking behaviors as well as the willingness of citizens to participate in early intervention programmes . 53

Case Study 4: Like Minds, Like Mine (LMLM) - New Zealand BACKGROUND

Like Minds, Like Mine is a public awareness programme for mental health in New Zealand that was started in 1997. It is funded by the New Zealand government and led by different portions of the government, including the Health Promotion Agency (HPA) and the Ministry of Health. They aim is to increase social inclusion and end discrimination towards people who experience mental illness or distress . By helping to eliminate 54

discrimination, they believe, this can facilitate increased mental health outcomes . To do so, their work is focused on three main areas: public awareness campaigns, community projects and research.

As part of their efforts to raise public awareness, LMLM created a set of media guidelines for journalists. These guidelines include preferred terminology and ideas on how to report mental health issues in a way that supports both hope and recovery . 55

Having these guidelines posted publicly not only allows for easy access for those in the media, but also allows readers to gain a better understanding of how negative portrayal

51 BeyondBlue. (2018). Annual Highlights 2017-2018. p.10. Retrieved from https://www.beyondblue.org.au/docs/default-source/default-document-library/bl1890_annual_highlights_web.pdf?sfvrsn=15dda8ea_2 52 Nous Group. (2014, May). Independent evaluation of beyondblue . p 3. Retrieved from https://www.beyondblue.org.au/docs/default-source/research-project-files/bw0265.pdf?sfvrsn=33739de9_0 53 Nous Group (2014, May). Independent evaluation of beyondblue . p 6. Retrieved from https://www.beyondblue.org.au/docs/default-source/research-project-files/bw0265.pdf?sfvrsn=33739de9_0 54 “About”. (2020, June 23). Like Minds, Like Mine. Retrieved from https://www.likeminds.org.nz/about/ 55 “Media Guidelines”. (2020, June 23). Like Minds, Like Mine . Retrieved from https://www.likeminds.org.nz/media/

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in the media can impact mental health stigma and discrimination. New Zealanders are also encouraged to join the LMLM Media Watch Facebook page, which allows them to challenge media articles and the portrayal of mental illnesses within the media . 56

With regard to community education projects, multiple different ones have been carried out across a variety of different sectors. Examples include: ‘No Worries’ (a workplace initiative), Psychological Medicine Education (focus within health settings) and Rakau Roroa (which focuses on supporting a growing network of leaders). Sample activities within these activities include toolkits, face-to-face workshops and social media engagement . 57


In a 2013 report published by the Royal Australian and New Zealand College of Psychiatrists, the impact of Like Minds, Like Mine was analysed. 1135 people participated in the survey, of which 48% thought that LMLM helped in reducing discrimination against people with mental illness, and 22% felt like LMLM assisted a little. That being said, a staggering 89% reported experiencing at least a little unfair treatment due to a mental health problem . This indicates that while LMLM has had a positive impact on mental 58

health awareness, there is still a lot more that needs to be done.

Case Study 5: Beyond the Label (BTL) - Singapore BACKGROUND

Beyond the Label (BTL) is a government-subsidized anti-stigma campaign in Singapore launched in September 2018. It is a five-year public education funded by the Tote Board Mental Health Strategic Initiative. The movement has five main objectives to: 1) raise awareness of stigma towards persons with mental health conditions, 2) celebrate the resilience, strength and contributions of persons in recovery from mental health conditions, 3) educate and equip the public with tips and knowledge to interact and support persons in recovery, 4) facilitate more conversations on mental health and 5)

56 “Like Minds, Like Mine Media Watch”. (2020, June 23). Facebook. Retrieved from https://www.facebook.com/groups/stigmawatch/ 57 “Community Education Projects”. (2020, June 23). Like Minds, Like Mine . Retrieved from https://www.likeminds.org.nz/about/community-education-projects/ 58 Thornicroft, C et al. (2014). Impact of the “Like Minds, Like Mine” anti-stigma and discrimination campaign in New Zealand on anticipated and experienced discrimination. Australian & New Zealand Journal of Psychiatry, 48(4), 360–370. Retrieved from https://www.ecald.com/assets/Resources/Like-Minds-Like-Mine-anti-stigma.pdf

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encourage more balanced reporting and portrayal of persons with mental health conditions in the news and media . 59

One of the key components of BTL is the ambassador programme . These 60

ambassadors are young professionals who have mental health conditions and have used their experience to help co-create the movement. BTL also provides a host of resources on how corporations and youth can get involved to move beyond the label . Although 61

BTL is currently the main anti-stigma campaign in Singapore, there are also smaller localized campaigns including the ‘Hidden Pain’ campaign by the Samaritans of Singapore (SOS), and the ‘Speak Up’ campaign by the National Council of Social Service (NCSS).


Due to the recent nature of Beyond the Label, there is yet to be a comprehensive evaluation of its impact on reducing stigma and increasing knowledge surrounding mental health. That being said, the impact of the smaller aforementioned ‘Hidden Pain’ and ‘Speak Up’ campaigns can be observed. The ‘Hidden Pain’ campaign by SOS encouraged viewers to pay attention to what lies beyond a happy expression, by presenting words that at first glance looked positive but revealed a negative message when flipped upside down . This campaign subsequently became viral, with people 62

globally reposting and tweeting about this campaign and raising awareness for suicide prevention.

Case Study 6: SMART - India BACKGROUND

The SMART mental health project is a large-scale project that was conducted in 42 rural villages across the south of India over three months . As part of this project, an 63

anti-stigma campaign was established. The anti-stigma campaign in India was developed in response to research showing a large treatment gap in low and middle-income countries due to mental health stigma, which served as a significant

59 “About the Beyond the Label campaign”. (2020, June 23). National Council of Social Service. Retrieved from https://www.ncss.gov.sg/Our-Initiatives/Beyond-The-Label/About-the-Campaign 60 “Our campaign ambassadors”. (2020, June 23). National Council of Social Service. Retrieved from https://www.ncss.gov.sg/Our-Initiatives/Beyond-The-Label/Our-campaign-ambassadors 61 “The Mental Health Public Education Grant Call”. (2020, June 23). National Council of Social Service . Retrieved from https://www.ncss.gov.sg/Our-Initiatives/Beyond-The-Label/What-we-can-do-to-address-stigma 62 “Samaritans of Singapore (SOS) Show Hidden Pain for Suicide Prevention Campaign”. (2013, June 19). AdAge. Retrieved from https://adage.com/creativity/work/hidden-pain/31937 63 Maulik, P.K., Devarapalli, S., Kallakuri, S., et al. (2017). Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach. Psychol Med , 47(3), 565-575. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244444/

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barrier to exercising help-seeking behavior . To measure the impact of the anti-stigma 64

campaign, 3676 participants were interviewed pre- and post-intervention phases.

Four main strategies were developed within this campaign: 1) developing printed information education and communication materials, 2) sharing of a lived experience, 3) developing a promotional video on mental health, stigma and SMART, as well as 4) staging a drama by a local theatre group . 65


Although knowledge of mental health amongst participants did not increase throughout the campaign, attitudes and behaviors improved significantly . For the most 66

part, participants did not differ in their responses pre- and post-intervention for knowledge domain statements, except for the statement ‘people with mental illness cannot live a good, rewarding life’ which post-intervention was significantly worse (with a standard deviation of 1.7 compared to the pre 2.1). This suggested that by the end of the campaign, unfortunately, more participants believed that having a mental illness served as a hindrance to enjoying a satisfying life . 67

There was, however, an overall increase in positive attitudes towards mental health, with more participants agreeing that people with mental health problems are less of a danger than what was typically assumed, and an increase in the number of people who believed it necessary to adopt a more tolerant attitude towards people with a mental illness . There was a decrease in standard deviation (from 1.9 to 1.7) in the 68

behavior domain, indicating an increased interpersonal tolerance surrounding mental health; for instance, people were more willing to live and work with someone with a mental health problem . Of the four strategies employed by the campaign, sharing of a 69

lived experience and staging a drama were found to be the most effective in inciting stigma reduction behavior and a change in attitude.

64 Maulik, P.K., Devarapalli, S., Kallakuri, S., et al. (2017). Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach. Psychol Med , 47(3), 565-575. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244444/ 65 Maulik, P.K., Devarapalli, S., Kallakuri, S., et al. (2017). Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach. Psychol Med , 47(3), 565-575. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244444/ 66 Maulik, P.K., Devarapalli, S., Kallakuri, S., et al. (2017). Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach. Psychol Med , 47(3), 565-575. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244444/ 67 Maulik, P.K., Devarapalli, S., Kallakuri, S., et al. (2017). Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach. Psychol Med , 47(3), 565-575. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244444/ 68 Maulik, P.K., Devarapalli, S., Kallakuri, S., et al. (2017). Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach. Psychol Med , 47(3), 565-575. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244444/ 69 Maulik, P.K., Devarapalli, S., Kallakuri, S., et al. (2017). Evaluation of an anti-stigma campaign related to common mental disorders in rural India: a mixed methods approach. Psychol Med , 47(3), 565-575. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5244444/

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Discussion

The six aforementioned case studies exemplify the tremendous impact of mental

health stigma-reduction organisations across the globe. Although the most comprehensive and evidence-based anti-stigma campaigns have been primarily based in the Western Hemisphere, prioritization of mental health has increased in the Asia Pacific, where various anti-stigma campaigns are gaining traction.

The effectiveness of these anti-stigma campaigns in reducing mental health stigma is largely a result of their varied approaches. Each of these campaigns tailored their methods towards their respective target groups, maximising success and sustainability. OM provides a great example of this; among their four different target groups, their approaches to youth compared to the workplace are distinct. For youth, the emphasis is placed on contact intervention and education through regional youth summits, whereas in the workplace, the emphasis is placed on pledges and provision of resources. One particular method utilized in multiple campaigns is derived from the social contact hypothesis, which suggests that the most effective way to reduce stigma in individuals is by spending time with someone who has experienced a mental health problem. This is a tried and tested strategy applied within effective campaigns including TTC’s ‘Time to Talk Day’ and ‘In Your Corner’, and OM’s MHCC Headstrong youth initiative, which invites participants to have vulnerable conversations and share personal stories on mental health. These methods, along with others, provide concrete indications and recommendations towards anti-stigma research and programme development for Mind HK moving forward.

Recommendations

● Continue to review programmes and outcomes of anti-stigma campaigns globally. Future campaigns to analyze include, but are not limited to, See Me (Scotland), Each of Us (Mental Health Europe), Make It OK (Global) and Thrive NYC (New York City).

● Identify and carefully choose potential local partners, both corporate and non-profit, for campaign partnerships. Messaging and values between organisations must align, to ensure Mind HK’s anti-stigma work is received appropriately.

● Implement a multi-pronged approach, using key components from the case studies.

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● Based on additional research and data analyses on mental health in Hong Kong, attitudes within populations, and available resources, Mind HK should identify target populations for the first two years.

● Implement programmes based on the social contact hypothesis (having people spend time with someone who has experienced a mental health problem); an evidence-based, effective method for removing the stigma around mental health.

● With the support of clinical professionals, develop training for mental health “ambassadors” to share their lived experience, from difficulties to recovery.

● Work with the media by providing resources and training to ensure coverage on mental health is destigmatising, rather than stigmatising.

Conclusion

Stigma and people’s preconceived notions of mental health have a big impact on

those with mental health issues. Whether institutionalized or self-induced, stigma can hinder recovery, slow down help-seeking behavior and affect the self-esteem of those affected. It is vital to challenge these behaviors and attitudes in order to decrease the treatment gap so that people get the help they need. Anti-stigma campaigns act as a catalyst to do this, by directly challenging societal notions and norms through education, contact intervention and advocacy. However, anti-stigma campaigns alone are not enough. In order to eradicate mental health stigma, tolerance and acceptance of mental health need to be internalized within a community.

Hong Kong lacks adequate resources and support to provide for the one in-seven people who suffer from a mental health issue. For those who do seek support, stigma and discrimination are present. The emergence of an anti-stigma campaign that actively challenges the perceptions of the Hong Kong people is necessary.

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Appendix:

TTC additional details:

1. Changing attitudes in the workplace ● Employer Pledge ● Employer Pledge Employee Champions ● Resources to support both employers and employees

The Employer Pledge is a commitment by the employer to support their employees’ mental health over time . Additional explanation documents and Powerpoint 70

presentations are provided to encourage organisations to sign the employer pledge . 71

TTC provides resources to help them do so (e.g. hand book on how to start a conversation, and signposting to support) . Sample activities for employers and 72

employees include: stigma word map, am I reeaally fine? and mental health myth buster. Additionally, training resources for employers are available . 73 74

2. Changing attitudes of children and young people (schools):

With regards to changing attitudes of children and young people, three main areas are being targeted: teachers, students and school leaders. Sample activities are provided below : 75

● Teachers: mental health assemblies, small group session (e.g. graffiti wall), student campaign resources, poster/screensavers, support for parents (e.g knowledge sheets)

● Students: how to start a student campaign ● School Leaders: support networks, utilizing social media to your advantage

3. Changing attitudes in communities

The main way in which Time to Change is changing attitudes in communities is through TTC champions (see changing attitudes in the workplace)

4. Campaigns ● In Your Corner ● Time to Talk Day

70 “Employer Pledge”. (2020, June 23). Time to Change. Retrieved from https://www.time-to-change.org.uk/get-involved/get-your-workplace-involved/employer-pledge 71 “Get your workplace involved”. (2020, June 23). Time to Change. Retrieved from https://www.time-to-change.org.uk/get-involved/tackle-stigma-workplace/get-your-workplace-involved 72 “Become a Champion in your workplace”. (2020, June 23). Time to Change. Retrieved from https://www.time-to-change.org.uk/get-involved/get-involved-workplace/champions-workplace 73 “Activities for your workplace”. (2020, June 23). Time to Change. Retrieved from https://www.time-to-change.org.uk/get-involved/get-involved-workplace/make-impact-your-workplace 74 “Support for employers”. (2020, June 23). Time to Change. Retrieved from https://www.time-to-change.org.uk/get-involved/tackle-stigma-workplace/support-employers 75 “Mental health resources for teachers”. (2020, June 23). Time to Change. Retrieved from https://www.time-to-change.org.uk/get-involved/get-involved-schools/5-ways-change-attitudes-your-school

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“About the Beyond the Label campaign”. (2020, June 23). National Council of Social Service. Retrieved from https://www.ncss.gov.sg/Our-Initiatives/Beyond-The-Label/About-the-Campaign

“About Us”. (2018, July 16). Time To Change. Retrieved from https://www.time-to-change.org.uk/about-us . “Activities for your workplace”. (2020, June 23). Time to Change . Retrieved from https://www.time-to-change.org.uk/get-involved/get-involved-workplace/make-impact-your-workplace “Ask Twice, People Urged, as New Research Shows Three Quarters of Brits Would Say They Are ‘Fine’ Even If Struggling with a Mental Health Problem.” (2018, Oct 3). Time To Change . Retrieved from https://www.time-to-change.org.uk/news/ask-twice-people-urged-new-research-shows-three-quarters-brits-would-say-they-are-%E2%80%98fine%E2%80%99-even

“Become a Champion in your workplace”. (2020, June 23). Time to Change. Retrieved from https://www.time-to-change.org.uk/get-involved/get-involved-workplace/champions-workplace

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Committee on the Science of Changing Behavioral Health Social Norms, et al. (2016). Approaches to Reducing Stigma. In Committee on the Science of Changing Behavioral Health Social Norms, et al. (Eds.). Ending Discrimination Against People with Mental and Substance Use Disorders. Washington (DC): National Academies Press (US). Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK384914/

“Community Education Projects”. (2020, June 23). Like Minds, Like Mine. Retrieved from https://www.likeminds.org.nz/about/community-education-projects/

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“Opening Minds” (2019, July 19). Mental Health Commission of Canada. Retrieved from https://www.mentalhealthcommission.ca/English/opening-minds

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“Our Global Work: What We Do”. (2018, Sept 3). Time To Change. Retrieved from https://www.time-to-change.org.uk/about-us/what-we-do/our-global-work/our-global-work-what-we-do “Our Latest Campaign”. (2017, Feb 22). Time To Change . Retrieved from https://www.time-to-change.org.uk/media-centre/our-latest-campaign

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“Samaritans of Singapore (SOS) Show Hidden Pain for Suicide Prevention Campaign”. (2013, June 19). AdAge. Retrieved from https://adage.com/creativity/work/hidden-pain/31937

“Stigma | Meaning of Stigma in English”. (2020). Lexico Dictionaries | English. Retrieved from https://www.lexico.com/definition/stigma Stuart, H., et al. (2014). Opening Minds in Canada: Background and Rationale. The Canadian Journal of Psychiatry , 59(1), 8–12. DOI:10.1177/070674371405901S04. “Support for employers”. (2020, June 23). Time to Change. Retrieved from https://www.time-to-change.org.uk/get-involved/tackle-stigma-workplace/support-employers “The Mental Health Public Education Grant Call”. (2020, June 23). National Council of Social Service. Retrieved from https://www.ncss.gov.sg/Our-Initiatives/Beyond-The-Label/What-we-can-do-to-address-stigma Thornicroft, C et al. (2014). Impact of the “Like Minds, Like Mine” anti-stigma and discrimination campaign in New Zealand on anticipated and experienced discrimination. Australian & New Zealand Journal of Psychiatry, 48(4), 360–370. Retrieved from https://www.ecald.com/assets/Resources/Like-Minds-Like-Mine-anti-stigma.pdf Tien, L. (2017). United States Model of Training Doctoral Level Clinical Psychologists. Retrieved from https://www.legco.gov.hk/yr17-18/english/panels/hs/papers/hscb2-174-1-e.pdf

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Time To Change. (2019). Our Impact. 2018/2019. Retrieved from https://www.time-to-change.org.uk/sites/default/files/TTC_Impact%20Report%20_FINAL%20VERSION.pdf “What We Do”. (2018, July 16) Time To Change. Retrieved from https://www.time-to-change.org.uk/about-us/what-we-do . “Who We Are and What We Do”. (2020, June 22). BeyondBlue. Retrieved from https://www.beyondblue.org.au/about-us/who-we-are-and-what-we-do “Workplace”. (2020, June 22). Mental Health Commission of Canada . Retrieved from https://www.mentalhealthcommission.ca/English/what-we-do/workplace

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About Mind HK Mind HK (Mind Mental Health Hong Kong Limited) is a registered S88 charity (91/16471) committed to improving awareness and understanding of mental health in Hong Kong. We collaborate with other local and international mental health charities and provide online support and training programmes, based on global best practice, to empower anyone experiencing a mental health problem and equip them with the resources they need. Through collaborative research, Mind HK is leading the way in understanding mental health problems in the city and providing its population with the right support and resources. For more on Mind HK and it’s mission and vision, please visit: www.mind.org.hk

In the development of this report, Mind HK would like to acknowledge Linden Gaultney, Elise Chan and Yen Kuok for their support.

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