Plain language summary
Mass media interventions for reducing stigma towards people with mental health problems
People define stigma in various ways. In this review we focus on two key aspects of stigma: discrimination (treating people unfairly because of the group they belong to) and prejudice (negative attitudes and emotions towards certain groups). People with mental health problems often experience stigma. It can have awful effects on their lives. Mass media are media that are intended to communicate with large numbers of people without using face-to-face contact. Examples include newspapers, billboards, pamphlets, DVDs, television, radio, cinema, and the Internet. Anti-stigma campaigns often include mass media interventions, and can be expensive, so it is important to find out if the use of mass media interventions can reduce stigma.
We reviewed studies comparing people who saw or heard a mass media intervention about mental health problems with people who had not seen or heard any intervention, or who had seen an intervention which contained nothing about mental ill health or stigma. We aimed to find out what effects mass media interventions may have on reducing stigma towards people with mental health problems.
We found 22 studies involving 4490 people. Five of these studies had data about discrimination and 19 had data about prejudice. We found that mass media interventions may reduce, increase, or have no effect on discrimination. We found that mass media interventions may reduce prejudice. The amount of the reduction can be considered as small to medium, and is similar to reducing the level of prejudice from that associated with schizophrenia to that associated with major depression. The quality of the evidence about discrimination and prejudice was low, so we cannot be very certain about these findings. Only three studies gave any information about financial costs and two about adverse affects, and there were limitations in how they assessed these, so we cannot draw conclusions about these aspects.
Interventions s'appuyant sur les médias grand public pour réduire la stigmatisation subie par les personnes souffrant de problèmes de santé mentale
Les gens définissent la stigmatisation de diverses manières. Dans cette revue, nous nous intéressons exclusivement aux deux aspects principaux de la stigmatisation : la discrimination (traiter différemment certains individus à cause de leur appartenance à un groupe social) et le préjudice (attitudes et sentiments négatifs envers certains groupes). Les personnes souffrant de problèmes de santé mentale sont souvent victimes de stigmatisation. Cela peut avoir des effets terribles sur leur vie. Les médias grand public sont les médias qui visent à communiquer avec de très grands nombres de personnes sans devoir utiliser le contact en face-à-face. Les exemples comprennent les journaux, les panneaux publicitaires, les brochures, les DVD, la télévision, la radio, le cinéma et le réseau Internet. Les campagnes anti-stigmatisation comprennent souvent des interventions s'appuyant sur les médias grand public, et peuvent être onéreuses, c'est pourquoi il est important d'établir si l'utilisation des interventions s'appuyant sur les médias grand public peut réduire la stigmatisation.
Nous avons examiné des études comparant des personnes qui ont vu ou entendu parler d'une intervention s'appuyant sur les médias grand public au sujet des problèmes de santé mentale avec des personnes qui n'ont vu ou entendu parler d'aucune intervention, ou qui ont vu une intervention qui n'avait rien prévu au sujet des problèmes de santé mentale ou de la stigmatisation. Notre objectif était de découvrir quels effets les interventions s'appuyant sur les médias grand public peuvent avoir sur la réduction de la stigmatisation subie par les personnes souffrant de problèmes de santé mentale.
Nous avons trouvé 22 études impliquant au total 4 490 participants. Cinq de ces études comprenaient des données sur la discrimination et 19 comprenaient des données sur le préjudice. Nous avons découvert que les interventions s'appuyant sur les médias grand public peuvent réduire, augmenter ou n'avoir aucun effet sur la discrimination. Nous avons constaté que les interventions s'appuyant sur les médias grand public peuvent réduire le préjudice. L'ampleur de la réduction peut être considérée comme étant faible à moyenne, et est similaire à la réduction du degré de préjudice allant de celui associé à la schizophrénie jusqu'à celui associé à une dépression majeure. La qualité des preuves sur la discrimination et le préjudice était faible, nous ne pouvons donc pas soutenir avec certitude ces résultats. Seules trois études ont fourni quelques informations sur les coûts financiers et deux autres sur les effets indésirables, mais compte tenu des limitations constatées au niveau de la méthode utilisée pour leur évaluation, nous ne pouvons pas tirer de conclusions sur ces aspects.
Notes de traduction
Traduit par: French Cochrane Centre 4th September, 2013
Traduction financée par: Pour la France : Minist�re de la Sant�. Pour le Canada : Instituts de recherche en sant� du Canada, minist�re de la Sant� du Qu�bec, Fonds de recherche de Qu�bec-Sant� et Institut national d'excellence en sant� et en services sociaux.
Massenmediale Interventionen zur Reduktion von Stigma gegen Menschen mit psychischen Problemen
Menschen definieren Stigma in unterschiedlichster Weise. In dieser Übersichtsarbeit richten wir unseren Fokus auf zwei wesentliche Aspekte von Stigma: Diskriminierung (das Behandeln von Menschen in einer unfairen Art und Weise aufgrund deren Zugehörigkeit zu einer bestimmten Gruppe) und Vorurteile (negative Einstellungen und Gefühle gegen bestimmte Gruppen). Menschen mit psychischen Problemen erfahren Stigma häufig. Dies kann furchtbare Auswirkungen auf ihre Leben haben. Massenmedien sind Medien, welche dazu bestimmt sind mit einer großen Menschenmenge zu kommunizieren ohne sich des direkten, unvermittelten Kontakts zu bedienen. Als Beispiele lassen sich Zeitungen, Plakate, Broschüren, DVDs, Fernsehen, Radio, Kino, und das Internet nennen. Anti-Stigma Kampagnen beinhalten häufig massenmediale Interventionen, welche teuer sein können. Daher ist es wichtig herauszufinden, ob der Einsatz von massenmedialen Interventionen Stigma reduzieren kann.
Wir begutachteten Studien, welche Menschen, die von einer massenmedialen Intervention zur psychischen Gesundheit gehört und diese gesehen haben mit jenen, die von einer solchen Intervention weder gehört noch diese gesehen haben. Die Kontrollgruppe konnte auch aus Menschen bestehen, die zwar eine Intervention gesehen haben, diese Intervention jedoch nicht die psychische Gesundheit oder Stigma thematisierte. Unser Ziel war es herauszufinden, welche Wirkungen massenmediale Interventionen im Hinblick auf die Reduktion von Stigma gegen Menschen mit psychischen Problemen haben.
Wir haben 22 Studien mit 4.490 Teilnehmern gefunden. Fünf dieser Studien lieferte Daten zu Diskriminierung und 19 zu Vorurteilen. Wir stellten fest, dass massenmediale Interventionen die Diskriminierung reduzieren oder steigern oder keinen Effekt auf sie haben können. Wir fanden zusätzlich, dass massenmediale Interventionen Vorurteile womöglich reduzieren können. Der Umfang der Reduktion kann als klein bis moderat eingestuft werden und ist ähnlich der Vorurteilsniveaus, welche mit Schizophrenie bis zu jenen von starken Depressionen assoziiert werden. Die Qualität der Evidenz zu Diskriminierung und Vorurteilen war niedrig, weshalb die Ergebnisse mit Vorsicht betrachtet werden müssen. Nur drei Studien lieferten Informationen zu finanziellen Kosten und zwei zu negativen Auswirkungen und es gab Einschränkungen dahingehend, wie diese erfasst wurden, wodurch wir zu diesen Aspekten keine Schlussfolgerungen ziehen können.
Anmerkungen zur Übersetzung
Koordination durch Cochrane Schweiz
Description of the condition
Stigma has been defined and conceptualised in a number of different ways. The conceptual framework used in this review is that stigma comprises ignorance (lack of knowledge), prejudice (stigmatising attitudes) and discrimination (being treated unfairly, a behaviour concept) (Thornicroft 2007). Our review focused on the latter two concepts: prejudice and discrimination, with knowledge as a secondary outcome. This is because what constitutes de-stigmatising knowledge is a contested issue. For example, Slade has described the paradigmatic arguments about fundamental ways (clinical models, disability models, diversity models) to understand experiences labelled as mental illness, and highlights the lack of agreement over these (Slade 2009). There is also significant disagreement between different professional groups about what treatments are helpful (Lauber 2005). Our focus on discrimination and prejudice was also because these are central to most conceptualisations of stigma, e.g. (Link 2001a, Corrigan 2005), but these other models only contain one aspect of knowledge, namely stereotype awareness. A further pragmatic consideration was that because the review covered interventions which did not have a stated aim of reducing stigma, having a stigma-related outcome was a key aspect in inclusion decisions. Whilst prejudice and discrimination are always stigma-related, knowledge is a much broader concept and may or may not be related to stigma, and therefore would have been problematic as a primary outcome.
Discrimination and prejudice were relevant concepts for this review because they focus on stigmatisers (the targets of the mass media interventions reviewed here) rather than stigmatised people. Some commentators focus on aspects of prejudice, viewing stigma as a social process of 'othering', blaming and shaming (Deacon 2006), whereas others have argued for a purely discrimination-based conceptual framework (Sayce 1998). Phelan and colleagues have investigated the possible similarity between the concepts of stigma and prejudice, and concluded that the two models have much in common, with most differences being a matter of focus and emphasis (Phelan 2008). Discrimination and prejudice are key elements in Rüsch's discussion of Link's (Link 2001a) conceptualisation of the stigma process as labelling, separation, stereotype awareness, stereotype endorsement, prejudice, and discrimination in a context in which social, economic, or political power is exercised (Rüsch 2005). Discrimination and prejudice are also core elements in Corrigan's framework (Corrigan 2005). In this review, in line with the Thornicroft 2007 model, we used the term 'discrimination' to refer to behavioural elements such as observed discriminatory behaviour and discrimination experiences reported by people with mental health problems, although we recognise that discrimination can also operate at the structural level, for example in discriminatory media reporting, policy and legislation (Corrigan 2004c). Following the same model, we used the term 'prejudice' to encompass concepts such as attitudes towards, stereotypes about, emotional reactions to, and desire for social distance from, people with mental ill health.
Mental health-related stigma is widespread. A recent survey of public reactions to case descriptions of people with schizophrenia and major depression, involving nationally-representative samples in 15 countries in Africa, Asia, Australasia, Europe, and in both North and South America, found significant levels of public stigma in all countries studied, although there was some variation between them (Pescosolido 2009). A US study using the same methodology found that in 2006, 62% of the public reported being unwilling to work closely with people with schizophrenia, and 52% were unwilling to socialise with them (Pescosolido 2010). The figures for depression were 47% and 30% respectively (Pescosolido 2010). Furthermore, some studies have reported a worsening of certain attitudes in recent years (Angermeyer 2005; Mehta 2009). A 2009 study investigating the discrimination experiences of 739 people with schizophrenia in 27 countries found that negative discrimination was experienced by 47% in making or keeping friends, by 43% from family members, by 29% in finding a job, 29% in keeping a job, and by 27% in intimate or sexual relationships (Thornicroft 2009). Stigma can be compounded by other axes of difference. For example people with mental ill health who belong to other groups facing stigma and discrimination, such as those from black and ethnic minority groups, lesbian and gay individuals, and asylum seekers, may be particularly disadvantaged (e.g. Gary 2005). Furthermore, both mental ill health itself and mental health-related discrimination and prejudice can make people more likely to become members of other groups subject to stigma, such as those experiencing homelessness, unemployment and poverty.
Stigma has major adverse effects on the lives of people with mental health problems (McDaid 2008). Public attitudes commonly include stereotypes of incompetence, beliefs about dangerousness, attributions of blame, expectations of poor prognosis, negative emotional responses, and a desire for social distance (Hinshaw 2000). Each of these can directly affect the well-being and quality of life of people with mental ill health. People with mental health problems experience significant discrimination which spans all major domains of life (Thornicroft 2006; Thornicroft 2009) and includes exclusion from employment (Stuart 2006b) with consequent poverty, negative impacts on intimate relationships and parenting (Hinshaw 2005), reduced access to and engagement with mental health services (Corrigan 2004b), and poorer physical health care (Jones 2008). Discrimination and prejudice can also have significant negative effects on the way that people with mental ill health feel about themselves, such as inducing internalised stigma (Corrigan 2002b; Ritsher 2003). In addition, the anticipation of discrimination can lead people to use strategies of avoidance and concealment, which may further contribute to social exclusion and poor quality of life (Thornicroft 2009). Mental health-related stigma also affects families and others close to the person with mental ill health, and these people can experience 'courtesy stigma' or 'stigma by association' (Corrigan 2004a). In addition stigma has damaging effects at the societal level, robbing the community of the contributions that people with mental ill health could make were it not for stigma, and helping to maintain fear about mental illness (Corrigan 2005). Negative media reporting - a form of discrimination in itself - also shapes attitudes and influences behaviour, thereby producing or reinforcing stigma (Wahl 1995).
Description of the intervention
Mass media has the potential to de-stigmatise as well as to stigmatise (Philo 2010). This review focused on mass media interventions, rather than on other types of intervention, because such interventions are able to reach large numbers of people and so have the potential for achieving population-level change. Large scale change may be difficult with other types of intervention.
Following Bala 2008 and Brinn 2010, we defined mass media as channels of communication intended to reach large numbers, which are not dependent on person-to-person contact. A mass media intervention is one that uses such channels. There are many different forms of mass media, for example: print (e.g. newspapers, magazines, billboards, pamphlets, flyers, coasters); recordings (e.g. audio cassettes, videos, CDs, DVDs); radio; television; cinema; mobile phones (e.g. mobile device applications); and the Internet (e.g. websites, blogs, podcasts, viral messaging, social networking sites) (Donovan 2003).
Not all mass media interventions that may reduce stigma have an explicit intention to do so. Examples may include the positive portrayal of a person with a mental health problem on television without a planned intention, or media coverage of a celebrity’s diagnosis with a mental illness. Some health promotion campaigns may also reduce stigma, even though this is not their primary purpose.
Interventions vary in the extent to which they target particular groups. Some are directed at the general population and some are targeted at specific groups, for example young people or employers. Mass media interventions may come from various sources, including governments, community groups and organisations. An intervention may focus on stigma in relation to mental ill health in general, a specific mental health condition, or all forms of disability including mental health disabilities. Interventions may be based, implicitly or explicitly, on diverse conceptualisations of stigma or mental health problems, and may use different theories to underpin the design of the interventions (see How the intervention might work). Interventions sometimes take place at a single time point, or may be short-term or sustained over a long period. Furthermore they vary in intensity (e.g. extent and frequency of advertising) and reach (e.g. proportion of intended population who see the advertisements).
How the intervention might work
In many respects, mass media interventions to combat stigma work using the same mechanisms operating in advertising and marketing. When these techniques are applied to address social issues rather than to sell commercial products or to promote a particular organisation, this is referred to as social marketing (Donovan 2003). However, it is recognised that social and commercial marketing differ in significant ways, most markedly in that the attitudes and behaviours which social marketing seeks to change are often more complex and hence more challenging to change than commercial behaviour (Donovan 2003).
Social marketing draws on several models of communication and persuasion, and uses various behaviour change theories. A number of these derive from, or overlap with, those from the health psychology, social psychology, public health or health promotion fields. Some of the major theories include: the theory of reasoned action; the health belief model; the transtheoretical (stages of change) model; the theory of planned behaviour; social learning theory; the Rossiter-Percy motivational model; the diffusion theory model; and the elaboration likelihood model (Donovan 2003; Noar 2006). Symbolic communication and modelling are also processes thought to be important in mass media interventions (Bandura 2001). The mass media operates by potentially influencing not only individuals but also communities and policy makers (Andreasen 2006).
It is not uncommon for mass media material to contain some form of personal narrative from people who have experienced mental health problems, such as celebrities, or members of the public sharing stories about themselves and their lives. These may reduce stigma because they are an indirect form of social/interpersonal contact with people with mental health problems, and this form of contact has been theorised, and demonstrated, to reduce stigma (Couture 2003; Pettigrew 2006; Corrigan 2012). Such narratives may also reduce stigma by increasing awareness of the variation amongst members of out-groups and in-groups, increasing social identity complexity, and increasing tolerance (Schmid 2009). Alternatively, narratives may act as 'mediated associations' in which an individual feels empathy towards the suffering of another without the other's physical presence, elicited through language (stories, films) or pictorial representation (e.g. photographs), with this empathy then being translated into a commitment to social justice (Kumagai 2008).
Our conceptualisation does not necessarily imply a linear mode of action with changes in prejudice leading to changes in discrimination. For example, a communication which imparts the message that it is unlawful to discriminate on the basis of mental health could change behaviour (discrimination) outcomes without necessarily changing attitudes (prejudice). Social marketing theory (Donovan 2003) states the importance of including a clear call to action. In England’s national anti-stigma programme (Henderson 2009), the current call to action is ‘It’s time to talk’ including directions to keep in touch with people with mental health problems. As the loss of friends and being shunned are common reported experiences of discrimination, this is an example of how mass media messages may directly address one form of discrimination. Additionally mass media may change perceptions of social norms, with the change in social norms leading to behavior changes, leaving individual attitudes untouched (Wakefield 2010). Furthermore, subtle factors in communication can influence social behaviour without necessarily being mediated by conscious choice (Bargh 1996) and so mass media may affect behaviour directly. It is also recognised that changes in attitudes may not necessarily translate into changes in behaviour (Marcus 1998). Equalities and human rights legislation have a significant potential to reduce discrimination (Callard 2012). However research in this area is limited and it is not currently known how legislative approaches compare to mass media approaches in their effectiveness in reducing discrimination against people with mental health problems. Protest is another approach for countering discriminatory behaviour. Corrigan has compared protest and other approaches including indirect contact (one form of mass media intervention), and found that protest-based interventions were rarely studied, and when they were they did not yield significant reductions in stigma, whilst indirect contact significantly reduced discriminatory intentions (Corrigan 2012).
Many variables are believed to influence the effectiveness of mass media interventions, including: whether an intervention is based on formative research; whether it has a theoretical basis; the degree of targeting; campaign intensity; the media channel (Noar 2006); and the 'ad creative' (the creative design and content of the intervention). In addition, whether the mass media element is part of a multi-faceted campaign (Link 2001b) and which particular messages are conveyed (Clement 2010) are likely to be important. Reviews of mass media interventions in other fields have reported that the duration of campaigns appears to be important, with campaigns of longer duration being more effective (e.g. Friend 2002). Furthermore, interventions that are effective in reducing stigma in high-income countries may not necessarily be effective if exported without modification to low- or middle-income countries (Rosen 2003) for reasons relating to both available resources and culture. Within one country an anti-stigma intervention may be received differently by different ethnic groups (Glasgow Anti Stigma Partnership 2007). We took many of these variables into consideration in planning the comparisons and subgroup analyses that were undertaken, as well as the data extraction for this review.
Why it is important to do this review
Stigma is highly prevalent and has serious adverse effects on the lives of people with mental ill health (as described above). Consequently there is a need to find effective ways to reduce mental health-related stigma. Mass media interventions are one of the most commonly used types of intervention, and they are being carried out throughout the world (Sartorius 2005; Callard 2008). National programmes aiming to reduce mental health-related stigma and containing mass media components are taking place in a number of countries, such as New Zealand (Vaughn 2004), England (Henderson 2009) and Scotland (Dunion 2005). Local and regional interventions are also widespread. Mass media interventions can be scaled-up with relative ease to the population-level and hence, if effective, are a feasible intervention for large-scale change. If mass media interventions were to produce only a small magnitude of change, this may translate into important impacts at the population level (Noar 2006). Although other types of interventions, such as direct social contact (Couture 2003), have occasionally been used on a large scale (Corrigan 2006; Evans-Lacko 2012a), this is unusual and presents greater implementation challenges than mass media approaches.
There is a recognised evidence gap in this field (Weiss 2006; Callard 2008). This systematic review synthesises what is currently known to enable future research to be appropriately focused. Such systematic investigation provides guidance for those who are planning initiatives, about whether mass media interventions are worthwhile; about optimal intervention design; and about any possible harm. As mass media interventions may be expensive (Austin 1998), evidence of ineffectiveness will free anti-stigma resources for other approaches.
A number of non-systematic reviews of mass media and other interventions to reduce mental health-related stigma have been undertaken, (for example Warner 2001; Pinfold 2005; Rüsch 2005; Sartorius 2005; Warner 2005; Callard 2008; Hinshaw 2008; McDaid 2008; Thornicroft 2008). Recently four systematic reviews of interventions to reduce mental health-related stigma have been conducted, but none focus on mass media interventions (Holzinger 2008; Schachter 2008; Yamaguchi 2011; Corrigan 2012). Our review adds to the growing body of systematic review evidence about the effectiveness of mass media interventions in other fields (Grilli 2002; Vidanapathirana 2005; Bala 2008; Brinn 2010). The systematic review of mass media anti-stigma interventions in mental ill health is likely to create a greater understanding of this vital area, and to help to underpin the development of future population-level interventions to combat mental health-related stigma.
Summary of main results
Our review identified 22 eligible studies with a total of 4490 participants, and 19 of these studies had primary outcome data. All studies were randomised controlled trials (RCTs) and were highly heterogeneous. Participants included the general population, employers, and students training for health/educational roles, but the majority (n = 13) involved other types of students. Interventions spanned Internet, audiovisual, audio and print media. Discrimination was assessed in only five studies, prejudice in all. Data on secondary outcomes were relatively sparse. Outcomes were most often assessed only immediately post-intervention (n = 14), although three studies had follow-up beyond six months (Yoshida 2002; Finkelstein 2008; Jorm 2010a).
For discrimination outcomes, one study (Woods 2002) found evidence of reduced discrimination but this was not replicated in two larger nearly identical studies by the same author (Woods 2003; Woods 2005), which found no evidence of effect, as did two further studies (Yoshida 2002; Penn 2003). The effect size was small or negligible for discrimination, and we conclude that these findings are compatible with mass media having either a positive effect, a negative effect or no effect on discrimination.
Our review showed that, overall, mass media interventions reduce prejudice and that the size of this effect can be considered small-to-medium (Cohen 1988) with standardised mean differences (SMDs) of -0.38, -0.38 and -0.49 for the three follow-up time-point categories (see Table 2). To further aid interpretation, we transformed effect sizes into the equivalent number of points on Link's Social Distance Scale (SDS) (Link 1999) using a population standard deviation of 0.59 for social distance in relation to schizophrenia using the SDS from the observational study, General Social Survey 1996, USA (Link 1999). On this scale, respondents can score a minimum of 1 and a maximum of 4. The overall median effect sizes for prejudice outcomes immediately post-intervention, at 1 week to 2 months and at 6 to 9 months are the equivalent of reductions of 0.22, 0.22 and 0.29 points on the SDS. We can further extrapolate from data about SDS scores for different mental health conditions (Link 1999) that the overall effects of mass media interventions found in our review are similar to reducing the level of prejudice from that associated with symptoms of schizophrenia (mean SDS 2.75) to the level associated with symptoms of major depression (mean SDS score 2.54) as the difference between the two is 0.21. The four members of the stakeholder group and review team with declared personal experience of mental ill health were asked to rate the importance of this degree of reduction, and three rated it as 'quite important' and one as 'slightly important'.
This overall finding of a small-to-medium reduction in prejudice conceals the considerable variation in the effects of different individual interventions. The prejudice subgroup findings help to explain some of this variation. The clearest pattern of evidence is for the presence of first-person narratives, which were found to be effective in reducing prejudice. Interventions with two or more components tended to reduce prejudice more than those with only one. Other findings are tentative due to the small number of interventions in subgroups..
The individual studies with large effect sizes merit comment. The two studies (Russell 1988; Finkelstein 2008) with large prejudice-reducing effects took place in atypical settings. The former was dated 1988 and was a much earlier study than the others; the latter was the only study in a non-high-income country. It is possible that there may have been higher baseline prejudice in these contexts, making it easier to achieve large change. Alternatively the large effects may be due to factors inherent in the interventions, the former using three mailings of postal booklets with social inclusion/human rights messages and the latter a computer-assisted educational programme containing personal narratives. The study with a large prejudice-increasing effect (Coleman 2005) was the only first-person narrative intervention to have a primarily biomedical message and the film’s title, 'Fires of the Mind: Dark Voices: Schizophrenia', emphasises acute illness. This highlights the importance of the type of narrative content.
Overall completeness and applicability of evidence
Completeness of evidence
There were a number of areas where the evidence was incomplete, thereby limiting the external validity of the review findings. Although two types of study design were eligible for inclusion, we located very few ITS studies and none that met the inclusion criteria of having defined start and end points and at least three time points before and after the intervention. This is surprising, as ITS designs are common in studies evaluating other types of mass media intervention (Grilli 2002; Vidanapathirana 2005). Only five included studies examined our primary outcome of discrimination, but all included studies examined prejudice, our other primary outcome. Discrimination, being a behavioural outcome, is more difficult to measure, but is of greater importance than prejudice for improving the lives of people with mental health problems. Data on all secondary outcomes were sparse. We found no studies conducted in lower-middle, middle or low income countries, and none in which the populations were children or adolescents. The populations studied did not cover the full range of target groups who may stigmatise people with mental ill health. Four involved the general public and a further four targeted students training for health-related professions. However, none targeted practising health professionals, and only one study included employers despite these groups being identified as common sources of mental health-related stigma (Schulze 2007; Brohan 2010).
None of the studies tested long-term (over three months) interventions and none investigated interventions combining more than one type of mass media, and yet these approaches are typical of several national and regional anti-stigma programmes, e.g.Vaughn 2004; Dunion 2005; Henderson 2009. These programmes also often combine mass media with non-mass media components. Although we only included studies where the mass media component comprised more than 50% of the intervention, we only located two studies combining mass media and non-mass media, so the evidence remains relatively incomplete in this regard. Some types of mass media were not investigated by any of the included studies, specifically television, radio, cinema and mobile phone media. Only one study included a celebrity narrative (Corrigan (submitted), intervention A), whereas this is relatively common in national mass media campaigns (e.g. Vaughn 2004; Henderson 2009). No studies addressed stigma arising from mental ill health at the same time as addressing stigma due to other attributes.
The data were incomplete in several studies, as many authors did not provide important details, e.g. about randomisation methods (see Characteristics of included studies); attrition (see Figure 2); and about numbers of participants contributing data to each study arm (e.g. see footnotes to Figure 6). Furthermore, means and standard deviations were not always reported in papers and sometimes had to be requested from the study authors, or estimated or derived from other sources.
Applicability and transferability of evidence
The findings cannot necessarily be transferred to other contexts, populations and interventions not covered in the review (described in the section above on the completeness of the evidence). There are also issues around feasibility and resources. Some interventions are likely to be too costly to implement in many settings, although not enough is known about costs to state which are most likely to be problematic to implement for this reason. The majority of the print and Internet interventions were text-based, and required some degree of literacy, which may preclude their use with some populations (Clement 2009). The availability of technology is a further factor which may limit the transferability of the findings. As anti-stigma interventions are often led by people with personal experience of mental health-related stigma or are conducted in partnership with them, their views will frequently shape the nature of mass media interventions used. For example, mental health professionals and people with mental ill health differ in their views about which types of messages should be included in anti-stigma interventions (Clement 2010). The values and preferences of people with mental health problems may also influence whether mass media interventions are used at all; they may prefer face to face interventions as these provide greater opportunities for personal empowerment and employment (Clement 2012).
Quality of the evidence
See Summary of findings for the main comparison. We had pre-specified in the protocol (Clement 2011) that the main outcomes for assessment of the quality of the evidence were: discrimination towards people with mental ill health; prejudice towards people with mental ill health; cost; and unforeseen adverse effects. We made a post-hoc decision to categorise discrimination as a critically-important outcome and the remainder as important. Although all of the studies were randomised controlled trials which are considered to provide a high quality of evidence due to their design, for each outcome in this review we considered study limitations, inconsistency of results, the indirectness of the evidence, imprecision or other considerations, and downgraded the quality where appropriate (Guyatt 2008).
Discrimination was assessed in five of the included studies. The evidence is affected by study limitations (risk of bias) as the majority (30/35) of 'Risk of bias' items were rated as unclear or high. We did not downgrade for inconsistency as the studies were fairly consistent in showing no evidence of effect. The discrimination measures were somewhat indirect, in that although four studies assessed behaviour in situations in which participants believed they would be interacting with a person with mental ill health, no observation of an actual interaction was made, and one study used participants' reports of their behaviour in real-life settings as its measure (Yoshida 2002). Also, for each type of discrimination outcome the behaviour is not an indicator of discrimination in every instance. Consequently we downgraded the evidence for indirectness. The studies were not considered imprecise as only a minority (2/5) had outcome data from less than 100 participants (Woods 2002; Penn 2003). No other limits were noted (lack of validity of outcome measures was already included in our 'Risk of bias' ratings). Consequently the quality of evidence for discrimination was downgraded by two levels to 'low' for this outcome.
All included studies assessed prejudice. There were study limitations due to risk of bias, as the majority (105/133) of the 'Risk of bias' indicators were classified as unclear or high risk. Overall the results were fairly consistent for 16 of the 19 studies with analysable outcome data (see Figure 6 and Figure 7); therefore the evidence was not downgraded for inconsistency. The evidence was limited by indirectness of study populations. with generic student samples commonly used as proxies for the general population. Imprecision was not a large problem as only a minority (5/19) of studies had outcome data from less than 100 participants. No other limits were noted. Consequently the quality of evidence for prejudice was also downgraded by two levels to 'low'.
No studies included any information on cost or cost effectiveness in papers. Three study authors provided data on the costs of the interventions on request (Demyan 2009; Matthews 2009; Jorm 2010a). These studies were not considered to be compromised by study limitations as the majority (12/21) of 'Risk of bias' items were rated as low risk, and there were only four high risk ratings. There was inconsistency of results, with costs varying widely. The data did not suffer from indirectness, but there was imprecision in the costs for two (Demyan 2009; Matthews 2009) of the three studies. Other considerations also limited the quality of the evidence such as the lack of cost-reporting in papers and lack of cost-effectiveness data. Consequently we downgraded the quality of the evidence by three levels to 'very low'.
Unforeseen adverse outcomes
Two studies contained statements about unforeseen adverse outcomes (Finkelstein 2008; Jorm 2010a). These studies were considered to be compromised by study limitations as the majority (9/14) of 'Risk of bias' items were rated as unclear or high risk. There was consistency of results and the data did not suffer from indirectness. However there was imprecision, in that one study did not formally assess adverse outcomes and neither specified their methods. No other limits were noted. Consequently we downgraded the quality of the evidence by two levels to 'low'.
Potential biases in the review process
We searched 11 databases, including grey literature databases and a non-English language database. Limited translation of the MEDLINE strategy to other databases (notably CINAHL, CENTRAL, EMBASE and PsycINFO) will have impaired sensitivity and specificity. The impact of these shortcomings is difficult to determine; it may have resulted in the loss of relevant studies and influenced the results of the review. Resource limitations precluded the conduct of new searches before publication. However the electronic searching was supplemented by checking of references, citations and websites and communication with experts, which yielded eight further studies, all unpublished. It is therefore feasible that all relevant studies have been identified. We welcome contact from any authors who believe their studies may be relevant to this review.
The restriction to RCTs and ITS studies meant that we were unable to consider data from other types of evaluation of mass media interventions such as qualitative evaluations and before and after studies. Although RCTs are the highest form of evidence for evaluating interventions, the RCTs in our review were subject to a number of biases and other limitations (see Figure 2; Quality of the evidence).
As 10 of the 22 studies had 2 or more active arms, in our main analysis we combined these, as per our protocol (Clement 2011). However the arms were often quite different and had different effects. This had the effect of making our overall findings more conservative than they might otherwise have been. A further issue was the multiplicity of prejudice outcome measures evident in 12 of the studies. In most of these, no primary outcome was defined by the study author and no power calculation was undertaken (our second basis for selecting the outcome for analysis). Consequently we used methods which select the outcome for analysis as being the one with the median effect size (Grimshaw 2003; Brennan 2009). This obscures larger effects found for some outcome measures.
Our pre-specified classification of all attitudinal and emotional outcomes into the single category of prejudice precluded the examination of possible differential effects on different types of prejudice. For example, some interventions may increase empathy but also increase social distance (Brown 2010 intervention B), or may reduce blame but increase assumptions about poor prognosis (Penn 2003).
It is possible that particular combinations of characteristics of a mass media intervention are important to its effectiveness, e.g. type of message within, for example, a personal narrative, using a particular medium. A hierarchical subgroup analysis might have been illuminating in this regard, but would have required substantially more data than were available in this review.
Agreements and disagreements with other studies or reviews
Our findings are broadly in line with other studies and reviews, whilst making an important additional contribution to the existing knowledge base. Several systematic reviews have investigated the effects of anti-stigma interventions which have included mass media interventions. A systematic review of 71 outcome studies using contact, education or protest-based approaches to reduce mental health-related stigma (Corrigan 2012) has recently reported findings relevant to our review. Corrigan and colleagues' review did not specifically address the effectiveness of mass media interventions of all types, but did compare outcomes for face-to-face and video-based contact, the latter being the equivalent of the mass media first-person narrative interventions in our review. They found that both approaches were beneficial (Corrigan 2012). The effect sizes found for video-based contact were smaller than those found in our review, with a mean d = -0.296 for attitudes and -0.197 for behavioural intentions (Corrigan 2012) compared to our finding of a median effect size of -0.51 on prejudice. This difference may be attributable to Corrigan's findings being based on all types of study design, not just RCTs. Corrigan and colleagues found video-based contact to be less effective than face-to-face contact (Corrigan 2012), although two RCTs have found the delivery modes to be equivalent (Reinke 2004; Clement 2012).
A systematic review of school-based interventions to reduce mental health-related stigma noted a dearth of RCT evidence, poor methods, considerable clinical heterogeneity, and inconsistent or null results (Schachter 2008). It recommend the development, implementation and evaluation of a curriculum which fosters the development of empathy and, in turn, an orientation toward social inclusion and inclusiveness. These effects may be achieved largely by bringing especially but not exclusively the youngest children into direct, structured contact with an infant, and likely only the oldest children and youth into direct contact with individuals experiencing mental health difficulties. Similarly, a narrative review of educational interventions for young people concluded that direct contact with people with mental health problems seems to be key in reducing stigmatisation, while the components of education and video-based contact conditions are still arguable (Yamaguchi 2011). A systematic review of target group-oriented interventions to reduce mental health-related stigma did not report any findings on the efficacy of mass media interventions, although some of the studies included in the review did have mass media elements (Holzinger 2008).
These reviews report that discrimination outcomes are rarely measured (Yamaguchi 2011; Corrigan 2012). Evaluations of national anti-stigma programmes which have mass media components have sometimes examined reports of discrimination experienced by people with mental ill health, and have found reductions in discrimination (Wyllie 2011; Henderson 2012). These studies did not use the types of study design eligible for inclusion in this review, but their findings suggest that anti-stigma programmes may have the potential to reduce discrimination. We found very little information about costs. McCrone and colleagues have applied economic modelling to data from Scotland's anti-stigma campaign (McCrone 2010). They report that If the campaign caused 10% of changed attitudes then it was estimated to cost £35 per one less person who felt that people with mental health problems were dangerous, and £186 per one less person who felt the public needs protection from people with mental health problems.
The problematic nature of biomedical messages apparent in our review has also been demonstrated in two recent systematic reviews on public attributions for mental illness and levels of stigmatisation (Angermeyer 2011; Schomerus 2012), and in a consensus development study (Clement 2010). The latter study recommended the use of ‘see the person’ messages, and our finding about the benefits of interventions echoes this. A systematic review of simulated hallucination interventions to reduce stigma (Ando 2011) was in accordance with this review's finding that such interventions can be problematic with regard to stigma, especially when not combined with pre- and post-simulation activities. However, the review's qualitative findings from studies which had included a pre-intervention DVD developed by a researcher with personal experience of hearing voices, and a post-simulation debriefing discussion, suggest that when delivered in this way, simulated hallucinations may have a number of beneficial effects.
When we compare our review findings with systematic review evidence about the effectiveness of mass media interventions in other fields, we find that studies on promoting HIV testing (Vidanapathirana 2005) and increasing health service utilisation (Grilli 2002) provided more consistent evidence for the effectiveness of mass media interventions than did the studies in our review. Our preliminary findings about the benefits of multi-component interventions echo Brinn and colleagues' finding that the more effective interventions tended to be more intensive (Brinn 2010). Our review is also in agreement with one on mass media and HIV testing (Vidanapathirana 2005) in highlighting the need for more research on different types of media, cost effectiveness and on the characteristics of messages.
Appendix 1. Cochrane Central Register of Controlled Trials search strategy
CENTRAL, The Cochrane Library, Issue 7, 2011
stigma OR discrimination OR prejudi* OR social perception OR social distance OR human rights
mental* OR psych* OR depress* OR schizo* OR bipolar OR anxiety OR substance OR alcohol OR dementia OR intellectual disabil* OR learning disabil* OR retardation OR anorex* or bulimi* OR obsessi* OR phobi* OR panic
media OR communication OR television OR radio OR film OR cinema OR movie OR newspap* OR internet OR video OR DVD OR publication OR advert* OR social market* OR campaign* OR messag* OR narrative OR social contact OR audio* OR virtual OR health promotion OR online
315 records found
Appendix 2. MEDLINE and EMBASE search strategy
MEDLINE (OvidSP),1966 to 15 August 2011
EMBASE (OvidSP) 1947 to 15 August 2011
2. (stereotyp* or stigma* or label* or negative image* or ignoran* or misconception* or misperception* or literacy or ((public* or community or social or popular) adj perception*)).tw.
3. social perception/
4. public opinion/
6. exp attitude/
7. ((public* or community or social or popular) adj attitude*).tw.
8. (((negative or positive or chang*) adj3 attitude*) or prejudice* or hostil* or intoleran*).tw.
9. social distance/
10. rejection psychology/
11. human rights/
12. (rights or discriminat* or marginali* or rejecting behavior or injustice* or (social adj (distance or justice or rejection or acceptance or exclusion or inclusion))).tw.
14. mental health/
15. mental health services/
16. exp mental disorders/
17. mentally ill persons/
18. ((mental* or psychiatr* or psychological* or developmental* or learning or substance*) adj (ill* or disorder* or disease* or distress* or disab* or problem* or health* or well-being or wellbeing or patient* or treatment or retardation)).tw.
19. ((chronic* or severe* or serious* or persistent) adj (mental* or psychiatr* or psychological*)).tw.
20. (emotional adj3 (disorder* or problem*)).tw.
21. (psychos#s or psychotic* or schizo* or depression or depressive or bipolar or mania or manic or obsessi* or panic or phobic or phobia or anorexi* or bulimi* or borderline or narcissis* or personality adj1 disorder or self injur* or self harm or dementia or substance abuse).tw.
23. exp mass media/
24. (mass communication or media or broadcast* or radio or television or cinema or film* or movie* or trailer* or journalis*).tw.
25. serial publications/
26. (newspaper* or magazin* or newsletter* or press).tw.
29. communications media/
31. electronic mail/
32. (electronic mail* or email* or e-mail* or webmail* or mailing list* or discussion list* or listserv*).tw.
33. cellular phone/
34. (((mobile or cell* or wireless) adj (phone* or telephone*)) or text messag* or texting or texted or sms or mms).tw.
35. tape recording/
36. optical storage devices/
38. (audio* or video* or cassette* or tape* or dvd* or compact dis* or cd or cds or multimedia or multi media).tw.
40. (internet or web or website* or online or blog* or weblog* or podcast* or portal* or e-communication* or electronic communication* or computer program* or computer mediated).tw.
41. video games/
42. video recording/
43.(apps or facebook or twitter or tweet or bebo or youtube or myspace or chatroom or chatroom or viral message or viral advert or wiki* or virtual*).tw.
46. user computer interface/
47. computer assisted instruction/
50. (pamphlet* or booklet* or leaflet* or flyer* or brochure* or print* media or print* material* or publication*).tw.
52. government publications as topic/
53. information dissemination/
54. (information adj2 (distribut* or disseminat*)).tw.
55. advertising as topic/
56. public relations/
57. persuasive communication/
58. famous persons/
59. ((famous adj (person* or people)) or celebrit*).tw.
60. social marketing/
61. (campaign* or message* or advert* or marketing or public relation* or publicity or public information or (communication adj (program* or strateg*)) or positive framing or (rais* adj2 awareness)).tw.
62. virtual or indirect or record* or film* or audio*) adj10 (social contact or testimony* or stor* or account* or experience* or narrative* or play or theat*)
63. Health promotion /
64. ((community or broadbased or broad based or public) adj3 education program*).tw.
65. (poster* or billboard* or ribbon* or button* or badge* or visual art* or street art* or (promotion* adj (item* or material*)) or festival* or entertainment).tw.
66. or/ 24-66
67. 13 and 23 and 67
68. randomized controlled trial.pt.
69. controlled clinical trial.pt.
74. evaluation studies.pt.
76. follow up studies/
77. prospective studies/
78. (experiment* or intervention*).tw.
79. (pre test or pretest or post test or posttest).tw.
80. (preintervention or postintervention).tw.
81. time series.tw.
82. time point*.tw.
84. exp animals/ not humans.sh.
85. 84 not 85
86. 68 and 86
3303 records found in MEDLINE
9530 records found in EMBASE
Appendix 3. PsycINFO search strategy
OvidSP, 1806 to 15 August 2011
2. (stereotyp* or stigma* or label* or negative image* or ignoran* or misconception* or misperception* or literacy or ((public* or community or social or popular) adj perception*)).tw.
4. social perception/
5. public opinion/
7. exp attitude/
8. ((public* or community or social or popular) adj attitude*).tw.
9. (((negative or positive or chang*) adj3 attitude*) or prejudice* or hostil* or intoleran*).tw.
10. social distance/
11. rejection psychology/
12. human rights/
13. (discriminat* or marginali* or rejecting behavior or injustice* or (social adj (distance or justice or rejection or acceptance or exclusion or inclusion))).tw.
15. mental health/
16. mental health services/
17. exp mental disorders/
18. mentally ill persons/
19. ((mental* or psychiatr* or psychological*) adj (ill* or disorder* or disease* or distress* or disab* or problem* or health* or well-being or wellbeing or patient* or treatment or retardation)).tw.
20. ((chronic* or severe* or serious* or persistent) adj (mental* or psychiatr* or psychological*)).tw.
21. (emotional adj3 (disorder* or problem*)).tw.
22. (((psychos#s or psychotic* or schizo* or depression or depressive or bipolar or mania or manic or obsessi* or panic or phobic or phobia or anorexi* or bulimi* or borderline or narcissis* or personality) adj1 disorder) or self injur* or self harm or dementia or substance abuse).tw.
24. exp mass media/
25. (mass communication or media or broadcast* or radio or television or cinema or film* or movie* or trailer* or journalis*).tw.
26. serial publications/
27. (newspaper* or magazin* or newsletter* or press).tw.
30. communications media/
32. electronic mail/
33. (electronic mail* or email* or e-mail* or webmail* or mailing list* or discussion list* or listserv*).tw.
34. cellular phone/
35. (((mobile or cell* or wireless) adj (phone* or telephone*)) or text messag* or texting or texted or sms or mms).tw.
36. tape recording/
37. optical storage devices/
39. (audio* or video* or cassette* or tape* or dvd* or compact dis* or cd or cds or multimedia or multi media).tw.
41. (internet or web or website* or online or blog* or weblog* or podcast* or portal* or e-communication* or electronic communication* or computer program* or computer mediated).tw.
42. Video games/
43. video recording/
44. (apps or facebook or twitter or tweet or bebo or youtube or myspace or chatroom or chatroom or viral message or viral advert or wiki* or virtual*).tw.
47. user computer interface/
48. computer assisted instruction/
51. (pamphlet* or booklet* or leaflet* or flyer* or brochure* or print* media or print* material* or publication*).tw.
53. government publications as topic/
54. information dissemination/
55. (information adj2 (distribut* or disseminat*)).tw.
56. advertising as topic/
57. public relations/
58. persuasive communication/
59. famous persons/
60. ((famous adj (person* or people)) or celebrit*).tw.
61. social marketing/
62. (campaign* or message* or advert* or marketing or public relation* or publicity or public information or (communication adj (program* or strateg*)) or positive framing or (rais* adj2 awareness)).tw.
63. ((virtual or indirect or record* or film* or audio*) adj10 (social contact or testimon* or stor* or account* or experience* or narrative* or play or theat*)).tw.
64. Health promotion/
65. ((community or broadbased or broad based or public) adj3 education program*).tw.
66. (poster* or billboard* or ribbon* or button* or badge* or visual art* or street art* or (promotion* adj (item* or material*)) or festival* or entertainment).tw.
68. 14 and 23 and 67
69. randomized controlled trial.pt.
70. controlled clinical trial.pt.
75. evaluation studies.pt.
77. follow up studies/
78. prospective studies/
79. (experiment* or intervention*).tw.
80. (pre test or pretest or post test or posttest).tw.
81. (preintervention or postintervention).tw.
82. time series.tw.
83. time point*.tw.
85. exp animals/ not humans.sh.
86. 84 not 85
87. 68 and 86
1808 records found
Appendix 4. CINAHL search strategy
EBSCOhost, 1981 to 16 August 2011
S55. s38 AND s54
S54. s50 NOT s53
S53. s51 NOT S52
S52. (MH "Human")
S51. (MH "Animals")
S50. s39 or s40 or s41 or s42 or s43 or s44 or s45 or s46 or s47 or s48 or s49
S49. (MH "Multiple Time Series")
S48. "preintervention or postintervention"
S47. "experiment* or intervention*"
S46. (MH "Comparative Studies")
S45. (MH "Crossover Design")
S44. (MH "Prospective Studies") OR "follow up stud*"
S43. "evaluation stud*"
S42. "trial or groups"
S41. "random* or placebo*"
S40. (MH "Clinical Trials") OR "controlled clinical trial"
S39. (MH "Randomized Controlled Trials")
S38. s13 and s21 and s35
S37. "randomized controlled trial or controlled clinical trial or random* or palcebo* or trial or groups or evaluation studies or evaluat* or follow up studies or prospective studies or cross over studies or comparative study"
S36. s13 and s21 and s35
S35. s22 or s23 or s24 or s25 or s26 or s27 or s28 or s29 or s30 or s31 or s32 or s33 or s34
S34. TX poster* or billboard* or ribbon* or button* or badge* or visual art* or street art* or promotion* or festival* or entertainment
S33. TX community or broadbased or broad based or public N3 education program*
S32. (MH "Health Promotion") OR "health promotion" OR (MH "Mental Health Promotion (Saba CCC)")
S31. TX campaign* or message* or advert* or marketing or public relation* or publicity or public information or communication or program* or strateg* or public figure* or persuasive communication or social marketing
S30. (MH "Selective Dissemination of Information") OR (MH "Consumer Health Information")
S29. (MH "Government Publications") OR (MH "Public Opinion")
S28. TX pamphlet* or booklet* or leaflet* or flyer* or brochure* or print* media or print* material* or publication*
S27. TX Blog* or apps or facebook or twitter or tweet or bebo or youtube or myspace or chatroom or chatroom or viral message or viral advert or wiki* or virtual* or software or hypermedia or user-computer interface or computer assisted instruction
S26. TX internet or web or website* or online or on line or blog* or weblog* or podcast* or portal? or e-communication* or electronic communication* or computer program* or computer mediated
S25. TX audio* or video* or cassette* or tape* or dvd* or compact dis* or cd or cds or multimedia or multi media or computer storage devices or optical disks or audiorecording or videorecording
S24. TX mobile or cell* or wireless N2 phone* or telephone*
S23. TX electronic mail* or email* or e-mail* or webmail* or mailing list* or discussion list* or listserv* or mobile or cell* or wireless phone* or wireless telephon* or text messag* or texting or texted or SMS or MMS
S22. TX mass communication or media or broadcast* or radio or television or cinema or film* or movie* or trailer* or journalis* or serial publications or newspaper* or magazin* or newsletter* or press
S21. S14 or S15 or S16 or S17 or S18 or S19 or S20
S20. TX psychos?s or psychotic* or schizo* or depression or depressive or bipolar or mania or manic or obsessi* or panic or phobic or phobia or anorexi* or bulimi* or borderline or narcissis* or (personality N1 disorder) or self injur* or self harm or dementia
S19. (MH "Affective Disorders") OR (MH "Affective Disorders, Psychotic") OR "emotional disorder"
S18. "psychiatric illness"
S17. (MH "Mental Retardation") OR "mental retardation" OR (MH "Mentally Disabled Persons")
S16. (MH "Attitude to Mental Illness") OR (MH "Mentally Disabled Persons") OR (MH "Psychosocial Aspects of Illness") OR "mentally ill persons"
S15. (MH "Mental Disorders") OR "mental disorders" OR (MH "Behavioral and Mental Disorders (Non-Cinahl)")
S14. (MH "Mental Health") OR "mental health" OR (MH "Mental Health Services")
S13. S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11 or S12
S12. "(rights or discriminat* or marginali* or rejecting behavior or injustice* or social) N5 (distance or justice or rejection or acceptance or exclusion or inclusion)"
S11. (MH "Human Rights") OR "human rights"
S10. "rejection psychology"
S9. "social distance"
S8. "(negative or positive or chang*) N5 (attitude* or prejudice*or hostil* or intoleran*)"
S7. "(public* or community or social or popular) N5 (attitude*)"
S6. (MH "Attitude") OR "attitude"
S5. (MH "Prejudice") OR "Prejudice"
S4. (MH "Public Opinion") OR "public opinion"
S3. "social perception"
S2. (stereotyp* or stigma* or label* or negative image* or ignoran* or misconception* or misperception* or literacy or public* or community or social or popular) N5 (perception*)
S1. (MH "Stereotyping")
401 records found
Appendix 5. ERIC search strategy
CSA, 1966 to 16 August 2011
2. stereotyp* or stigma* or label* or negative image* or ignoran* or misconception* or misperception* or literacy or public* perception or community perception or social perception or popular perception
3. social perception or public opinion or prejudice or attitude or hostil* or intoleran* or social distance or rejection psychology or human rights
4. discriminat* or marginali* or rejecting behavio?r or injustice* or social distance or social justice or social rejection or social acceptance or social exclusion or social inclusion
6. mental health or mental health services or mental disorders or mentally ill persons or mental* or psychiatr* or psychological* or well-being or wellbeing or patient* or treatment or retardation
7. psychos* or psychotic* or schizo* or depression or depressive or bipolar or mania or manic or obsessi* or panic or phobic or phobia or anorexi* or bulimi* or borderline or narcissis* or personality or self injur* or self harm or dementia or substance abuse
9. mass media or communication or mass communication or media or broadcast* or radio or television or cinema or film* or movie* or trailer* or journalis* or serial publications or newspaper* or magazin* or newsletter* or press or journalism or publishing or communications media or telecommunications or electronic mail or electronic mail* or email* or e-mail* or webmail* or mailing list* or discussion list* or listserv*
10. cellular phone or mobile or cell* or wireless or phone* or telephone*or text messag* or texting or texted or sms or mms or tape recording or optical storage devices or multimedia or audio* or video* or cassette* or tape* or dvd* or compact dis* or cd or cds or multimedia or multi media
11. internet or web or website* or online or blog* or weblog* or podcast* or portal* or computer program* or computer mediated or video recording or apps or facebook or twitter or tweet or bebo or youtube or myspace or chatroom or chatroom or viral message or viral advert or wiki* or virtual* or software or hypermedia or user computer interface or computer assisted instruction
12. pamphlet* or booklet* or leaflet* or flyer* or brochure* or print* or material* or publication* or information dissemination or advertising or public relations or famous persons or celebrit* or social marketing or campaign* or message* or advert* or marketing or public relation* or publicity or public information or positive framing or community or broadbased or broad based or public education or program or poster* or billboard* or ribbon* or button* or badge* or visual art* or street art* or promotion* or festival* or entertainment
14. 5 and 8 and 13
15. randomized controlled trial or controlled clinical trial or random or placebo* or trial or groups or evaluation studies or evaluat* or follow up studie or prospective studies or cross over studies or comparative study or time series or time point*
16. animals NOT humans
17. 15 NOT 16
18. 14 and 17
1782 records found
Appendix 6. Social Science Citation Index search strategy
ISI, 1956 to 16 August 2011
2. (stereotyp* or stigma* or label* or negative image* or ignoran* or misconception* or misperception* or literacy or ((public* or community or social or popular) near/1 perception*))
3. “social perception”
4. “public opinion”
7. ((public* or community or social or popular) near/1 attitude*)
8. (((negative or positive or chang*) near/3 attitude*) or prejudice* or hostil* or intoleran*)
9. “social distance”
10. “rejection psychology”
11. “human rights”
12. discriminat* or marginali* or “rejecting behaviour” or injustice* or (social near/1 (distance or justice or rejection or acceptance or exclusion or inclusion)))
14. “mental health”
15. “mental health services”
16. “mental disorders”
17. “mentally ill persons”
18. ((mental* or psychiatr* or psychological*) near/1 (ill* or disorder* or disease* or distress* or disab* or problem* or health* or well-being or wellbeing or patient* or treatment or retardation))
19. ((chronic* or severe* or serious* or persistent) near/1 (mental* or psychiatr* or psychological*))
20. (emotional near/3 (disorder* or problem*))
21. (((psychos?s or psychotic* or schizo* or depression or depressive or bipolar or mania or manic or obsessi* or panic or phobic or phobia or anorexi* or bulimi* or borderline or narcissis* or personality) near/1 disorder) or self injur* or “self harm” or dementia or “substance abuse”)
23. “mass media”
24. (“mass communication” or media or broadcast* or radio or television or cinema or film* or movie* or trailer* or journalis*)
25. “serial publications”
26. (newspaper* or magazin* or newsletter* or press)
29. “communications media”
31. “electronic mail”
32. (electronic mail* or email* or e-mail* or webmail* or mailing list* or “discussion list*” or listserv*)
33. “cellular phone”
34. (((mobile or cell* or wireless) near/1 (phone* or telephone*)) or “text messag*” or texting or texted or sms or mms)
35. “tape recording”
36. “optical storage devices”
38. (audio* or video* or cassette* or tape* or dvd* or compact dis* or cd or cds or multimedia or “multi media”)
40. (internet or web or website* or online or blog* or weblog* or podcast* or portal* or e-communication* or “electronic communication*” or “computer program*” or “computer mediated”)
41. “video recording”
42. (apps or facebook or twitter or tweet or bebo or youtube or myspace or chatroom or chatroom or “viral message” or “viral advert” or wiki* or virtual*)
45. “user computer interface”
46. “computer assisted instruction”
49. (pamphlet* or booklet* or leaflet* or flyer* or brochure* or print* media or print* material* or publication*)
51. “government publications as topic”
52. “information dissemination”
53. (information near/2 (distribut* or disseminat*))
54. “advertising as topic”
55. “public relations”
56. “persuasive communication”
57. “famous persons”
58. ((famous near/1 (person* or people)) or celebrit*)
59. “social marketing”
60. (campaign* or message* or advert* or marketing or “public relation*” or publicity or public information or (communication adj (program* or strateg*)) or “positive framing” or (rais* near/2 awareness))
61. ((community or broadbased or “broad based” or public) near/3 “education program*”)
62. (poster* or billboard* or ribbon* or button* or badge* or “visual art*” or “street art*” or (promotion* near/1 (item* or material*)) or festival* or entertainment)
64. 13 and 22 and 63
65. “randomized controlled trial”
66. “controlled clinical trial”
71. “evaluation studies”
73. “follow up studies”
74. “prospective studies”
75. “cross over studies”
76. “comparative study”
77. (experiment* or intervention*)
78. (“pre test” or pretest or “post test” or posttest)
79. (preintervention or postintervention)
80. “time series”
81. “time point*”
83. animals/ not humans
84. 82 not 83
85. 64 and 84
3663 records found
Appendix 7. OpenSIGLE search strategy
http://www.opengrey.eu/) 1980 to 2005, searched 18 August 2011, 2005 date of final entry to database
(stigma OR discrimination OR stereotype* OR social perception OR public opinion OR attitude)
(mental health OR mental health disorders OR mentally ill persons OR mental* or psychiatr* OR psycholog* OR eating disorder OR psycho* OR bipolar OR substance abuse OR anxiety) AND (mass media OR media OR communication OR radio OR television OR cinema OR film OR newspap* OR advertising)
46 records found
Appendix 8. Worldcat search strategy
OCLC, 1978 to 18th Augsut 2011
stigma OR discrimination OR prejudi* OR social perception OR social distance OR human rights
(mental* OR psych* OR depress* OR schizo* OR bipolar OR anxiety OR substance OR alcohol OR dementia OR intellectual disabil* OR learning disabil* OR retardation OR anorex* or bulimi* OR obsessi* OR phobi* OR panic) AND
(media OR communication OR television OR radio OR film OR cinema OR movie OR newspap* OR internet OR video OR DVD OR publication OR advert* OR social market* OR campaign* OR messag* OR narrative OR social contact OR audio* OR virtual OR health promotion OR online)
random* OR trial OR time series OR time point
80 records found
Appendix 9. metaRegister of Controlled Trials search strategy
http://www.controlled-trials.com/mrct/mrct_about.asp, 1973 to 18 August 2011
0 records found
Differences between protocol and review
The protocol for this review is Clement 2011.
Types of outcome measure
We had originally planned to include discriminatory behavioural intentions under discrimination (stigmatising behaviour), but elected to treat these as under prejudice (stigmatising attitudes) as an intention is more akin to an attitude than a behaviour.
Data extraction and management
A post-hoc decision was made not to use the 'see the person' message type, as this message type only arose when interventions contained personal narratives and if we had categorised these as having a 'see the person' primary message we would have missed messages contained in what the narrators said (or other aspects of the intervention). We also decided post-hoc to include commonly-used categories of primary message that were not in Clement 2010. We had not pre-specified the method of deciding which message was primary and decided this would be undertaken independently by two authors who would resolve disparities by discussion, and with arbitration if necessary.
We had not specified methods for classifying levels of risk for outcome measures in our protocol, therefore, through discussion (SC EB, SEL and FL), we established the following pragmatic criteria. We rated as high risk: measures developed by the study authors with no psychometric data reported; measures for which the authors reported a Cronbach's alpha of < 0.7; and un-referenced measures. We rated as 'unclear': referenced measures with no psychometric data reported; referenced measures with no statement that the measure was reliable or valid; and validated measures being used for the first time in a different type of population. We rated as low risk: measures which study authors reported had a Cronbach's alpha of 0.7 or greater, or referenced the measure as being reliable or valid.
Measures of treatment effect
Standardised mean differences rather than mean differences were calculated, as different measures were used for the same outcome and this precludes the use of mean differences. We did not pre-specify actions if data were skewed data. When this was the case the data were transformed into the logarithmic scale using methods described by Higgins and colleagues (Higgins 2008).
Unit of analysis issues
It was clarified that where intervention arms fell into different subgroups each intervention arm was compared to the control group and the possibility of meta-analysis was only considered within each subgroup, thereby avoiding potential unit-of-analysis errors. We had not made an a priori plan for dealing with studies with two control groups. When this arose we selected the one that was most similar to the intervention, that is an intervention containing irrelevant material rather than a no intervention control.
Where there was an even number of outcomes, we made a post-hoc decision, after consultation with the Cochrane Consumers and Communication Review Group, to follow Brennan 2009 and to select the outcome with the n/2 ranked effect size (using data from the final follow-up point when there were two or more follow-up points). A post-hoc decision was also needed about which outcome to select when multiple outcomes were used in studies with median data. In these cases, on the advice of UK Cochrane Centre training staff, we used an adapted version of the methods proposed by Grimshaw 2003 and Brennan 2009 whereby, after checking that the interquartile ranges were similar, we examined medians at the latest time point and selected the one ranked (n+1)/2 when there was an odd number of outcomes and the one ranked n/2 when there was an even number. Because standardised mean differences rather than mean differences were used, baseline differences are not reported. The review author group discussion to decide about the appropriateness of meta-analysis was originally planned as a face-to-face meeting but altered to an email discussion for practical reasons, and given that for the vast majority of comparisons meta-analysis was precluded on statistical grounds. We planned to produce a 'Summary of findings' table using GRADEprofiler (GRADEpro) software. In the event the 'Summary of findings' table was produced using the template in RevMan, but still following the GRADE approach (Guyatt 2008).
The main analysis became, in effect, a subgroup analysis by timing of outcome, as we had not anticipated the issue of differential follow-up time points. This approach was undertaken because it was not appropriate to combine outcomes assessed immediately post-intervention with those assessed at six months or longer, and because issues of multiplicity would have arisen for studies with more than one follow-up time point, had we not separated the data by follow-up time point. In the remaining subgroup analyses we selected the earliest follow-up time point as the one to present data for. We found that there were two unanticipated types of intervention: simulated audio-recordings, and interventions containing third-person narratives. As we considered each of these to be sufficiently distinct from the groups already listed in our subgroup analysis, these groups were added into the analyses post-hoc. As no mobile phone, broadcast media or cinema interventions were found, we did not refer to these and they did not appear in the 'type of media' subgroup analysis. There was just one intervention - a CD-ROM - that fell in the 'other' category for media type and a decision was made to group this in the Internet category as Internet-delivery would not have materially changed participants' experience of the intervention.
As minimal meta-analysis was warranted we examined the effects of removing studies at risk of bias and less precise studies primarily through examining changes in median effect sizes. We had intended to test for small study effects of binary outcomes by performing the arcsine-Thompson test, but this was precluded because we found only two studies with binary primary outcomes, and these had very different timings of outcome (immediate and 9 months). Where reporting bias was discovered we planned to investigate the impact in a sensitivity analysis, but this did not prove possible (see Effects of interventions), as the only studies for which meta-analysis was possible had identical bias. As we found that three of the multi-arm studies included arms that the study authors considered unlikely to reduce stigma (Reinke 2004; Brown 2010; Corrigan (submitted)), we undertook a post-hoc sensitivity analysis to examine the effects of removing these studies.
Quality of the evidence
We had pre-specified in the protocol the main outcomes for assessment of the quality of the evidence, but had not specified which would be categorised as critically important and which as important. We made a post-hoc decision to categorise discrimination as a critically important outcome and the remainder as important.