REDUCTION OF MENTAL HEALTH RELATED STIGMA AND DISCRIMINATION: GLOBAL OVERVIEW December 2024 World Bank Group Ministry of Health and Welfare of the Republic of Korea National Center for Mental Health of the Republic of Korea © 2024 / The World Bank 1818 H Street NW, Washington DC 20433 Telephone: 202-473-1000; Internet: www.worldbank.org Some rights reserved. This work is a product of The World Bank. The findings, interpretations, and conclusions expressed in this work do not necessarily reflect the views of the Executive Directors of The World Bank or the governments they represent. The World Bank does not guarantee the accuracy, completeness, or currency of the data included in this work and does not assume responsibility for any errors, omissions, or discrepancies in the information, or liability with respect to the use of or failure to use the information, methods, processes, or conclusions set forth. 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Reduction of Mental Health related Stigma and Discrimination: Global Overview. © World Bank.” Any queries on rights and licenses, including subsidiary rights, should be addressed to World Bank Publications, The World Bank, 1818 H Street NW, Washington, DC 20433, USA; fax: 202-522-2625; e-mail: pubrights@worldbank.org. © Jiyoung Park / ACRES International. Used with the permission of Jiyoung Park / ACRES International. Further permission required for reuse. Table of Contents 1. EXECUTIVE SUMMARY .............................................................................................................. 1 2. THE IMPORTANCE OF STIGMA AND DISCRIMINATION IN MENTAL HEALTH ................................... 3 3. DEFINING STIGMA AND DISCRIMINATION .................................................................................. 4 3.1. Public stigma ...................................................................................................................... 4 3.2. Self-stigma ......................................................................................................................... 4 3.3. Family stigma...................................................................................................................... 5 3.4. Structural stigma ................................................................................................................. 5 4. EVIDENCE ON HOW TO REDUCE MENTAL HEALTH STIGMA AND DISCRIMINATION ....................... 6 4.1. Methods ............................................................................................................................. 6 4.2. Structural stigma ................................................................................................................. 6 4.3. Public stigma ...................................................................................................................... 9 4.4. Specific intervention components ...................................................................................... 15 4.5. Self-stigma ....................................................................................................................... 17 4.6. Cost-effectiveness ............................................................................................................ 19 5. OVERVIEW OF CASE STUDIES OF NATIONAL-LEVEL ANTI-STIGMA PROGRAMS ........................... 20 6. CONCLUSIONS AND RECOMMENDATIONS .............................................................................. 32 APPENDIX 1. REFERENCES ......................................................................................................... 33 APPENDIX 2. DETAILED CASE STUDIES OF NATIONAL ANTI-STIGMA PROGRAMS ........................... 47 1. ‘Time to Change’ program, England ........................................................................................ 47 2. Nōku te Ao o program (previously called Like Minds, Like Mine), New Zealand ........................... 50 3. batyr program, Australia ........................................................................................................ 52 4. Time to Change Global program, Africa and India .................................................................... 55 5. Understanding Stigma and Strengthening Cognitive Behavioral Interpersonal Skills program, the Caribbean .................................................................................................................................... 58 6. NA ROVINU (On the Level) program, Czech Republic ............................................................... 59 7. Working Minds program, Canada ........................................................................................... 61 8. More Than a Label program, Hong Kong .................................................................................. 64 9. Mental Health Supporter Training program, Japan ................................................................... 66 10. ‘Beyond the Label’ program, Singapore ............................................................................... 68 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Acronyms BNBR Basic Needs Basic Rights BTL Beyond the Label CAMI Community Attitudes on Mental Illness Scale CBM Christian Blindness Mission CCBC Collaborative Community-Based Care CINAHL Cumulative Index to Nursing and Allied Health DISC Discrimination and Stigma Scale ERIC Education Resources Information Center FCDO Foreign, Commonwealth and Development Office FGD Focus Group Discussion GKT Gatekeeper Training IOPPN Institute of Psychiatry, Psychology and Neuroscience KCL King’s College London LMIC Low- and Middle-Income Country MAKS Mental Health Knowledge Scale MATES Mates in Construction Programme MH Mental Health MHFA Mental Health First Aid NCSS National Council of Social Service NGO Nongovernmental Organization NIMH CZ National Institute of Mental Health, Czechia OMS-HC Opening Minds Stigma Scale for Health Care Providers PMHC People with Mental Health Conditions RIBS Reported and Intended Behaviour Scale R2MR Road to Mental Readiness SROI Social Return On Investment SSCI Social Science Citation Index TLC3 Targeted, Local, Credible, Continuous Contact TTC Time to Change TTCG Time to Change Global TIM The Inquiring Mind TWM The Working Mind WHO World Health Organization Reduction of Mental Health Related Stigma and Discrimination: Global Overview Acknowledgements This report was led by Sheila Dutta (Senior Health Specialist, HAEH2) and Kate Mandeville (Senior Health Specialist, HEAH2). The authors are Graham Thornicroft (Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College London), Sue Baker, (Changing Minds Globally), Petra C. Gronholm (Centre for Global Mental Health and Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College London), Claire Henderson (Centre for Implementation Science, Institute of Psychiatry, Psychology and Neuroscience, King’s College London), Ahram Han (Consultant, ITSTI), Su Jin Yang (Director, National Center of Mental Health), and Young Sook Kwack (President, National Center of Mental Health). The authors would like to thank all the contributors to the country case studies, including Shreya Rao and Shaquille Graham (Nōku te Ao, New Zealand), Micheal Pietrus (Working Minds programme/Opening Minds, Canada), Robert O'Leary and Genesis Lindstrom (batyr, Australia), Sosei Yamaguchi, Daisuke Nishi, Naoaki Kuroda, Ai Aoki (Mental Health Supporter Training Programme, Japan), Carol Liang, Odile Thiang and Candice Powell (More Than A Label, Hong Kong), Elaine Loo, Pooja Nair and Li San Tan (Beyond the Label, Singapore). This work was conducted under the general guidance of Mara Warwick (Country Director, EACMK), Jason Allford (World Bank Group Special Representative, CEA10), Ronald Mutasa (Practice Manager, HEAH1), Caryn Bredenkamp (Practice Manager, HEAH2), and Maria Ana Lugo (Lead Economist and Program Leader (HEADR). The report was edited and formatted by Priya Thomas and Susi Victor. This work was funded by the Ministry of Economics and Finance and reviewed by the Ministry of Health and Welfare, Republic of Korea. This work would not have been possible with the support of the World Bank Group Korea Office. 1 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 1. EXECUTIVE SUMMARY Stigma and discrimination contravene basic human rights and have detrimental effects on people with mental health conditions by exacerbating marginalization and social exclusion—including by reducing access to mental and physical health care and diminishing educational and employment opportunities. The stigma and discrimination surrounding mental health have negative consequences for social exclusion in relation to education, the workplace, and the community, as well as for marital prospects, loss of property, inheritance, or rights to vote, and poor quality health care for mental and physical health conditions. Stigma powerfully and adversely affects individuals, families, communities, and society, and exists across all countries and cultures. A recent global survey of people with mental health conditions across 45 countries found that 80 percent agreed that “stigma and discrimination can be worse that the impact of the mental health condition itself.” The overall objective of this policy note, prepared jointly by the World Bank Group and Korean National Center for Mental Health, is to summarize global evidence for effective interventions to reduce mental health-related stigma and discrimination. The first section of this report defines stigma and discrimination, describes the adverse impact on the lives of people with mental health conditions, and summarizes results of a narrative literature review of the evidence base for interventions addressing mental illness-related stigma and discrimination. This report involved a synthesis of over 260 systematic reviews on stigma reduction and presents a detailed summary of the global evidence on how to reduce stigma and discrimination (building on earlier findings of the Lancet Commission on Ending Stigma and Discrimination in Mental Health). This review examined evidence regarding intervention impacts and summarizes key findings. Notably, this global review indicates that interventions based on the principle of social contact (whether in person, virtual, or indirect), that have been appropriately adapted to different contexts and cultures, are the most effective ways to reduce stigmatization worldwide. Global experience, over the past 25 years, demonstrates that it is feasible to scale up anti-stigma programs to the national level to effectively reduce stigma and discrimination in large-scale populations. Consequently, the second section of this report focuses on examining implementation experiences of delivering anti-stigma and discrimination programs and includes case studies that have developed effective and evidence-based initiatives. These case studies were selected purposively to enable representation of different types of anti-stigma and anti-discrimination interventions, across a range of geographical/cultural contexts and diverse target groups. These purposively selected case studies summarize how programs were designed, implemented, evaluated, and scaled up. The case studies demonstrate how evidence-based principles for anti-stigma interventions can be adapted and put into effective practice in a range of countries and contexts and cultures across the world. Although stigma and discrimination still seem to be one of the most neglected aspects of mental health, as these case studies show, in some countries there had been a significant shift with the transformation of mental health policy leading to the welcome transition of services from institution-based care to community-based care and support. However, the need to educate communities and transform attitudes, to create more supportive and inclusive communities and ultimately support recovery beyond the provision of treatment of symptoms, is often overlooked. The COVID-19 era has increased awareness of the need for programs that challenge mental health stigma and support earlier help-seeking and self-care. As highlighted in this analysis, most of the case study programs have adapted global evidence-based methods—with many positive impacts reported and much learning to share. Some key components include social contact, lived experience champions/ambassadors to share their mental health experiences at social contact events and online, social marketing campaigns, targeted programs with health care professionals, employers, schools, 1 Reduction of Mental Health Related Stigma and Discrimination: Global Overview universities and youth audiences, and the media. Specific lessons derived from the case studies include the following: • Social contact should be implemented with contextual and cultural adaptation to each setting. Social contact can be effective either delivered directly (in person) or indirectly (using remote, digital, and online methods). Additionally, the evidence for social contact implies that the direct involvement of people with lived experience of mental health conditions, in co-leading the program design, delivery, and evaluation, is necessary. • Long-term programs are necessary for sustainable stigma reduction. • Impact can be assessed by evaluating the program, by establishing a baseline assessment before the program starts, followed by periodic assessments of progress to stigma reduction. • Reducing stigma can lead to increased help-seeking by people with mental health conditions. • Better access to care for people with mental health conditions is expected to lead to shorter duration of symptoms and disability, greater educational attainment, lower suicide rates, less presenteeism and absenteeism in the workplace, and greater productivity for people whose mental health conditions have been treated early and well. This briefing paper proposes the following specific recommendations: 1. Plans must be created to fund, implement, and evaluate long-term programs to reduce mental health stigma and discrimination. 2. The central component of these plans is to use the evidence-based active ingredient of social contact for stigma reduction. 3. People with a full range of mental health conditions, including more severe conditions, need to actively contribute to these plans by co-leading the design, delivery, and evaluation of the programs. 4. Specific key target audiences and outcomes need to be identified at the outset of each program. 5. The programs must operate with widespread cross-sectoral support and participation, for example with the industry, sports, music, television, film, health care, and educational sectors. A detailed evaluation of impacts and outcomes must be conducted for each program and compared with an initial baseline assessment of key metrics. 2 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 2. THE IMPORTANCE OF STIGMA AND DISCRIMINATION IN MENTAL HEALTH The stigma and discrimination with regard to mental health have negative consequences for social exclusion in relation to marital prospects, education, the workplace, and the community; loss of property, inheritance, or rights to vote; and poor-quality health care for mental and for physical health conditions. Stigma powerfully and adversely affects individuals, families, communities, and society, and exists across all countries and cultures. These pernicious barriers to full citizenship and social participation share one fundamental characteristic—they contravene basic human rights which are intended to apply equally to everyone. Indeed, a recent global survey of 391 people with mental health conditions from 45 countries worldwide found that 80 percent agreed that “stigma and discrimination can be worse that the impact of the mental health condition itself” (Thornicroft et al. 2022). This World Bank policy note is structured as follows. First, the terms ‘stigma’ and ‘discrimination’ are defined. The next section describes how stigma and discrimination adversely affect the lives of people with mental health conditions—a more detailed account was published in The Lancet Commission on Ending Stigma and Discrimination in Mental Health (Thornicroft et al. 2022). A detailed summary of the global evidence on how to reduce stigma and discrimination is presented here, which summarizes and updates the evidence synthesis of the Lancet Commission. It would be useful to read this report in close conjunction with the Lancet Commission report. We have considered practical case study examples that demonstrate how these evidence-based principles for anti-stigma interventions can be adapted and put into practice in a range of countries, contexts, and cultures across the world. This briefing note closes with a series of recommendations which are intended for discussion and elaboration in terms of their relevance and applicability in different contexts. 3 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 3. DEFINING STIGMA AND DISCRIMINATION Stigma and discrimination can be defined in terms of four components, as shown in Figure 1. The term stigma stems from ancient Greek and originally referred to a tattoo, which was used to visibly mark slaves or criminals as members of society with a diminished value (Thornicroft et al. 2022). In the social sciences, the term stigma was elaborated in the second half of the twentieth century by Goffman (1963), who defined stigma as a ‘deeply discrediting’ attribute which reduces a person “from a whole and usual person to a tainted discounted one.” A separation is therefore created between ‘us’ and ‘them’, based on the belief that the labelled people are fundamentally different from, and of lower value than, other people. Discrimination is the unfair treatment of a person or a group of people because of a particular characteristic, such as people who have lived experience of mental health conditions. The stigmatization of people with mental health conditions needs to be considered within the broader frameworks of justice, social equity, and human rights. Figure 1. Types of stigma Family stigma 3.1. Public stigma Public stigma has three components: knowledge, attitudes, and behaviors. The knowledge component usually refers to a lack of knowledge in populations about mental health conditions (ignorance) and to misinformation that is often found in popular discourse and is part of local beliefs. Such misconceptions include, for example, beliefs about the dangerousness or incompetence of people with mental health conditions, or the belief that such conditions cannot be treated, or are due to a curse (Corrigan et al. 2003). Attitudes refer almost entirely to the negative emotional reactions of people in the general population toward people with mental health conditions, such as fear or disgust. Behavior refers to the rejection and social exclusion of people with mental health conditions, namely discrimination (Pescosolido et al. 2013; Thornicroft, Rose, and Kassam 2007). 3.2. Self-stigma Self-stigma, or internalized stigma, occurs when people with mental health conditions are aware of the negative stereotypes of others, agree with them, and turn them inwards against themselves. The internalization of negative beliefs can lead to diminished self-esteem and self-efficacy, and a ‘why 4 Reduction of Mental Health Related Stigma and Discrimination: Global Overview try’ effect. This occurs when people with mental health conditions give up important life goals, such as seeking a job or engaging in friendships, because they feel they will not be able to succeed (Corrigan and Watson 2006). 3.3. Family stigma Family stigma is also known as ‘stigma by association’, ‘courtesy stigma’, or ‘affiliate stigma’. This refers to stigma and discrimination as experienced by family members, as well as mental health staff, that is, people who are in close contact with people with mental health conditions. Such stigma seems to depend on the type of condition. If a mental health condition is considered hereditary, or due to karma, this can incur loss of face and greater stigma (Mak and Cheung 2012). Similarly, conditions that are believed to adversely affect marital prospects can also damage the reputation of family members of people with mental health conditions (Shi et al. 2019). It is also common for staff working in physical health care settings to have negative attitudes toward staff who work in mental health settings, which are seen as less prestigious, for example, within the field of medicine. 3.4. Structural stigma Structural stigma (also called systemic or institutional stigma) refers to policies and practices that work to the disadvantage of people with mental health conditions. Structural stigma has been defined as “societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatized” (Hatzenbuehler and Link 2014). Stigma is often seen as a barrier to policy change. It can play out in a lack of public demand for governmental action and investment and in misinformation, misunderstanding and lack of awareness of positive policy options among policy makers. Further examples of structural stigma include the fact that people with mental health conditions commonly experience restrictions in employment, voting, property ownership, marriage, and divorce (Thornicroft 2006). Another aspect of structural stigma relates to low levels of financial and human resources, since fewer resources are allocated to research and treatment for mental health than for physical conditions (Chisholm et al. 2019). An important consequence of structural stigma is that worldwide, most people with mental health conditions do not receive treatment. For depression and anxiety, for example, this treatment gap is estimated to be about 95 percent in low-income countries, 90 percent in middle-income countries, and 70–80 percent in high-income countries (Thornicroft et al. 2017). In addition, people with mental health conditions have less access to health care in general, and receive poorer quality of services, which leads to a 10- year mortality gap for all people with mental health conditions, and a 20-year mortality gap for people with severe mental health conditions (Walker, McGee, and Druss 2015). 5 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 4. EVIDENCE ON HOW TO REDUCE MENTAL HEALTH STIGMA AND DISCRIMINATION 4.1. Methods We conducted a review of systematic reviews of interventions intended to reduce stigma. We searched seven databases (PsycInfo, Medline, EMBASE, Cumulative Index to Nursing and Allied Health (CINAHL), Education Resources Information Center [ERIC], Global Health, Social Science Citation Index [SSCI]) for English language literature reviews. Searches were run on December 12 and 15, 2021, for the Lancet Commission on Ending Stigma and Discrimination in Mental Health (Thornicroft et al. 2022) and updated on April 14 and 16, 2024 (all databases except SSCI). The search included four concepts: stigma and discrimination, interventions, review, and mental health conditions. Individual search strategies including specific subject headings were developed for each database. This review therefore includes and updates the Lancet Commission umbrella review. Any review (systematic, meta-analysis, scoping, rapid, umbrella, or narrative) was eligible for inclusion. Reviews were included if they appraised qualitative or quantitative findings of interventions which aimed to reduce stigma in relation to a mental health condition. All countries and age groups were included. Interventions were included if a stigma or stigma-related outcome (for example, attitudes, beliefs, knowledge, mental health literacy, social inclusion) was either the primary or secondary outcome. The umbrella review was registered with Prospero, registration number CRD42022299682. The searches yielded 21,180 entries. After removing 9,526 duplicates, 11,654 titles or abstracts were screened. Irrelevant studies (n = 11,151) were excluded, and 503 full texts were assessed for eligibility. A total of 267 reviews were included, not all of which are cited due to some being of lower quality as well as overlap in the included studies, and hence the conclusions drawn. Here we summarize the findings for structural, interpersonal, and self-stigma. 4.2. Structural stigma 4.2.1 Policies A few reviews targeted policies. Identified studies investigated the impact of various professional and public initiatives to reduce stigma and discrimination against people with depression in Slovenia (Valic, Knifton, and Svab 2013) and case studies on dismantling mental health and substance use related structural stigma in Canadian health care settings (Sukhera and Knaak 2022). The included studies found positive outcomes from reducing structural stigma through policies; however, the quality of many studies was low. Policies aiming to establish respect toward people with mental health conditions and stipulating their rights on their own fall short in effectively reducing discrimination. More effective policies, legislation, and plans were often linked with community-based treatment, programs for public education, and media activities including participation of ‘champions’ with lived experience of mental health conditions and changing power relationships to allow shared understanding of the problem and alignment of values. The Canadian exemplars showed promise in improving access, health quality, and outcomes related to reduced coercion, and policy and practice change. This required managing resistance proactively, embracing disruptive innovation, and fostering trust through dialogue. Several national programs against stigma and discrimination in Asia were found to reduce experienced and anticipated stigma among people with mental health conditions and to facilitate help-seeking and engagement with mental health care, yet no data were available on whether they had actually increased access to mental health care. The potential impact of policy interventions targeting structural stigma is high, however, more research is needed on their cultural sensitivity, effectiveness, and cost-effectiveness. 6 Reduction of Mental Health Related Stigma and Discrimination: Global Overview In some East Asian countries, using a different term for schizophrenia was used as a strategy to reduce public stigma. There is some evidence that after the name change more people with schizophrenia were informed about their diagnosis (Yamaguchi et al. 2017). However, there is no evidence for positive effects on public attitudes or media reporting (Corrigan 2018). It is likely to be helpful if diagnostic terms which cause offense are revised with the involvement of people who have been given these diagnoses. Effective efforts to address structural stigma at the policy level have also included national mental health plans and policies and anti-discrimination laws to protect the rights and interests of people with mental health conditions in care, at work, and in wider society. Coalitions of stakeholders, often led by nongovernmental organizations (NGOs), mental health associations, and mental health professionals, with the participation of empowered people with lived experience, have played key roles in advocating for these changes. Descriptive studies have, for example, reviewed mental health parity with health policies in Commonwealth countries (Bhugra et al. 2018), and legislative mechanisms for social participation rights of people with depression in the Asia Pacific region (Ricci, Lee, and Chiu 2004). However, evaluations of the effect of such policies on people’s lives, knowledge, attitudes, and behaviors have not been carried out. Potential future policy interventions include policies to make it mandatory for insurance companies to cover mental health conditions and not to exclude people from purchasing medical insurance (Zhang et al. 2019). 4.2.2 Access to care We included seven reviews that stated how the intervention addressed stigma as a barrier to access or focused on knowledge, attitudes, or behaviors toward help-seeking to increase access. Four focused on high-income countries (Arundell et al. 2020; Joshi et al. 2021; Rosvik et al. 2020; Werlen et al. 2019) and three had no limitations (Greene, Bina, and Gum 2016; Choi and Easterlin 2018; Xu et al. 2018). Three focused on any mental health condition (Arundell et al. 2020; Greene, Bina, and Gum 2016; Xu et al. 2018), two on children and adolescents (Choi and Easterlin 2018; Werlen et al. 2019), one on people with dementia or suspected dementia (Rosvik et al. 2020 22), and one on pregnant women using opioids (Joshi et al. 2021). Greene, Bina, and Gum (2016) found that psychoeducation was the most used strategy to increase continuity of care for adults with mental health conditions in outpatient services. The interventions empowered service users by involving them in decision-making about appointments and follow-up schedules, while seeking information about their mental health condition and identifying treatment goals. The positive effect size increased with the number of specific treatment targets. Xu et al. (2018) identified 97 studies on interventions to increase help-seeking behaviors across populations with and without mental health conditions, of which three were in middle-income countries and none in a low-income country. Some used psychoeducation or cognitive-behavioral strategies to enhance motivation to seek help. The results showed positive short-term effects on attitudes, intentions, and behaviors to seek help, and positive long-term effects on help-seeking behavior. They also found long-term positive effects of collaborative care training for primary care or community-care staff on mental health service use among individuals in primary care settings. Joshi et al. (2021) found that training health care providers to share non-stigmatizing messages with pregnant women who used opioids increased acceptability of services and access. Rosvik et al. (2020) concluded that increasing awareness of community services improved their uptake among people with dementia and their caregivers, but that there was a knowledge gap on which interventions had the most impact. Arundell et al. (2020) used a review to identify strategies addressing stigma-related barriers to care: increasing inclusivity in programs for individuals with disabilities (for example, hearing aids, Braille, sign language); providing audiovisual displays and diagrams for people with low literacy or communication problems; using culturally relevant tools for individuals from minoritized groups; co- creating interventions with communities; training staff in communicating more effectively with marginalized communities such as migrants; or using positive language in educational materials. Choi and Easterlin (2018) reviewed interventions designed to improve access to behavioral health services 7 Reduction of Mental Health Related Stigma and Discrimination: Global Overview among young people in the US, concluding that while there is evidence that discussions between older adolescents and nurses or counsellors can be effective, for younger children it was essential to educate parents. A review focusing on children and adolescents (Werlen et al. 2019) identified 13 studies on universal school-based interventions and 21 studies on at-risk individuals. Most (80 percent) studies on treatment engagement for individuals at risk (for example, a family-based session to increase motivation in an emergency room) improved access. They concluded that two-stage interventions to identify people in need and then engage them in health care are necessary for a population-level effect on improving children’s access to mental health care. 4.2.3 Access to work and employment We found four reviews on interventions to increase access to work by reducing structural level stigma. One included a meta-analysis which suggested that training managers to understand and support the mental health needs of employees is effective in improving mental health related knowledge, non-stigmatizing attitudes, and self-reported supportive behavior (Gayed et al. 2018). The other reviews provided narrative syntheses of the results. An earlier review by Szeto and Dobson (2010) found no evaluation data; likewise, a review of the cost-effectiveness of initiatives to reduce stigma in the workplace found no eligible studies (Nogues and Finucan 2018). The authors pointed out that future researchers could make a clearer business case for stigma interventions by showing how stigma prevents employees from participating in employer-sponsored programs and by testing the cost efficiency of interventions involving manager training and anti-stigma components. A review by Mallick and Islam (2022) focused on partnerships between adult community mental health teams and disability employment services for people with severe mental illness in Australia. Their findings suggest that individual placement and support is an effective employment model, yet it is vital to address barriers hindering its expansion and implementation and the obstacles for individuals to participate in it. Interventions which aim to reduce interpersonal stigma in the workplace and improve mental health knowledge, confidence in offering help, and attitudes toward seeking help, notably Mental Health First Aid (MHFA) have been evaluated (Hanisch et al. 2016; Ramirez-Vielma et al. 2023; Roche et al. 2024; Toth et al. 2023). One review focused on small and medium enterprises (Toth et al. 2023) and another on male-dominated industries (for example, construction, mining) (Roche et al. 2024). These interventions reflected multimodal programs with education components, occasional contact strategies, and digital delivery. They were generally effective for mental health literacy and help- seeking intentions and attitudes. There was less evidence for help-offering and help-seeking behaviors and mental health stigma (Ramirez-Vielma et al. 2023). Further, as Szeto and Dobson (2010) observed, this type of intervention should be evaluated using employers’ data: provision of workplace accommodations; staff sickness rates; and levels of employment of people who disclose a mental health condition in response to equal opportunities monitoring questionnaires. Also, interventions could be improved through use of logic models and the theory underpinning their content (Roche et al. 2024). Reviews of studies on interventions to support people to gain work cover intellectual disability (Nevala et al. 2019), autism (Khalifa et al. 2020), severe mental illnesses (Kinoshita et al. 2013), and other mental health conditions (Probyn et al. 2021). Most measure change at the individual level, although vocational workers can also work with employers with potential for structural change. There is a knowledge gap for interventions addressing structural stigma in low- and middle-income countries (LMICs), where formal employment is less frequent. In particular, there is a lack of evidence on how to address the systematic exclusion of people with mental health conditions from community development programs, livelihood opportunities, or microfinance schemes. Such programs are fully in line with the key theme of the United Nations Sustainable Development Goals to ‘Leave no-one behind’ (UN 2015). 8 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 4.3. Public stigma 4.3.1. Children, adolescents, youth, and students A total of 55 reviews covered children, adolescents, teachers, parents, and university students (excluding health care students). Most targeted mental health conditions in general or suicide, while five covered autism, four covered developmental or intellectual disabilities, and one each covered addiction and schizophrenia specifically. Stigma and discrimination were addressed as primary outcomes in 23 of these, aiming to reduce negative attitudes, social distance, or peer victimization, or enhance social inclusion of peers affected by mental health conditions. Stigma was addressed through (a) education via lectures, texts, or internet-based programs; (b) interactive elements such as group discussions; or (c) contact with people with lived experience, either directly or indirectly via videos or the internet. Gaiha et al. (2021) focused on arts interventions (for example, theatre, creative writing) to reduce mental health related stigma among 10–24-year-old youth. Overall, the results indicated positive effects for the use of art to address stigma related to mental health conditions among youth, although the study quality ranged from weak to moderate. A meta-analysis showed that arts interventions are generally effective when using multiple art forms, although the effects were small. Rodríguez-Rivas et al. (2022) examined technology-based interventions (for example, video games, audiovisual simulation of hallucinations, virtual reality, and electronic contact with mental health services users) to reduce stigma among high-school and university students. Their meta-analysis demonstrated that these interventions had a consistent medium effect on reducing the level of public stigma. Ten systematic reviews with stigma as a primary outcome focused on young people with developmental disabilities, such as intellectual disabilities or autism spectrum disorders. One review concluded that the highest quality studies more often showed the interventions assessed to be effective (Morris, O'Reilly, and Nayyar 2023). Sentenac et al. (2012) identified a study that showed reduced peer victimization after an average of 25 weeks of involvement in a program using social contact to bring peers with and without disabilities together for shared activities in school and community settings. Kim et al. (2024) reviewed interventions to reduce stigma toward autistic people, which frequently involved digital delivery, based largely on educational elements with some studies also including first-person accounts or direct interactions with people with autism. Both randomized controlled trials (RCTs) and non-randomized studies suggested reductions in stigma; however, caution is needed in interpretation due to limitations in study design. Similarly, Settanni, Kern, and Blasko (2023) reviewed studies with educational and contact elements and found that, overall, the interventions had a positive impact on attitudes toward people with autism. Several reviews indicate that direct social contact with children with disabilities can lead to improved attitudes among peers if such meetings are structured (Louw, Kirkpatrick, and Leader 2020; McManus, Saucier, and Reid 2021; Sentenac et al. 2012) and if children, of equal status, with and without disabilities are involved (Sentenac et al. 2012). Combining multiple strategies (for example, Birnschein, Paisley, and Tomeny 2021; Cremin et al. 2021; McManus, Saucier, and Reid 2021; Morris, O'Reilly, and Nayyar 2023; Sentenac et al. 2012) and providing different types of information (that is, descriptive, explanatory, directive) is more effective than a single strategy (Birnschein, Paisley, and Tomeny 2021; Cremin et al. 2021). Allowing children to actively engage in the intervention and giving them strategies to interact with peers with mental health conditions seems the most promising approach (Birnschein, Paisley, and Tomeny 2021; McManus, Saucier, and Reid 2021). Most of these studies were carried out in schools, but a more recent review (Louw, Kirkpatrick, and Leader 2020) found a variety of interventions to enhance social inclusion within the community, such as photovoice, dog-walking, peer support, or participation in sports. Another review noted that recent interventions frequently utilized online platforms (Kim et al. 2024). Improving the social skills of children affected with mental health conditions led to better social inclusion, possibly because these children behaved 9 Reduction of Mental Health Related Stigma and Discrimination: Global Overview in a more socially accepted manner (Cremin et al. 2021; Louw, Kirkpatrick, and Leader 2020). For future studies, it would be important to differentiate changes in children’s social skills and in stigma among their peers. Although there are some promising results regarding behavioral outcomes, most studies focused on knowledge and attitudes. One qualitative study included in Morris, O'Reilly, and Nayyar (2023) found that a theme of difference (‘us’ versus ‘them’) emerged post intervention, which requires further investigation. Two reviews conclude that findings for intended behavior are more varied, and how far children’s actual behavior can be predicted from self-reported behavioral intentions is not clear (Cremin et al. 2021; Morris, O'Reilly, and Nayyar 2023). Stigma was included as a secondary outcome in 25 reviews which primarily focused on interventions which aimed to increase help-seeking among children, adolescents, and youth. They also aimed to support parents, teachers, or peers with gatekeeper training (GKT) on how to recognize signs of mental health conditions, how to intervene, and where to refer children, adolescents, or youth to ensure that they received adequate support and care. Positive attitudes toward mental health conditions and confidence in providing support were identified as important outcomes. Turning to interventions for schoolteachers, Anderson et al. (2019) reviewed eight studies about providing information about the signs and symptoms associated with common adolescent mental health problems. They found positive results at follow-up. Costardi et al. (2023) reviewed digital mental health interventions (for example, brief online simulations, web-based information or programs, online courses). These interventions showed promising results in enhancing mental health knowledge, preparedness, confidence, and attitudes, indicating their potential for improving mental health literacy. In relation to suicide, a systematic review summarized interventions among students and staff at high schools and universities (Breet et al. 2021). The findings indicated that universal interventions were effective in changing attitudes at post intervention with a small effect size, but none of the assessed interventions showed sustained changes at follow-up. For interventions that focused on stigma, results showed that psychoeducation and interpersonal contact had sustained positive impact at one-month follow-up. One intervention resulted in significant and sustained improvements in participants’ attitudes toward suicide. In addition, an ‘electronic bridge’ mental health service, including personalized feedback and online counselling, significantly decreased personal stigma scores with a large effect and reduced public stigma among high-risk college students with a medium effect. For teachers, Torok et al. (2019) found that none of the included studies reported specific effects for measures of attitudes toward suicide, while one study found that parental attitudes improved, but that this effect was not maintained later. Regarding mental health prevention and mental health literacy programs, the results are more mixed. In a meta-analysis, Salazar de Pablo et al. (2020) found a small effect for changes in attitudes toward people with mental health conditions across 16 studies with youth of different ages. Liang et al. (2023) conducted a meta-analysis of MHFA among college students (ages 19–27 years), showing no significant effect on stigma-related attitudes across four studies. Ng et al. (2021) conducted a review of studies of MHFA among teenagers and youth. Among teens, three of four studies that measured stigmatizing attitudes found a statistically significant improvement. For youth MHFA, six studies measured stigmatizing attitudes, four of which reported significant effects. Reis et al. (2022) examined mental health literacy training programs other than MHFA. They included five studies that met the minimum quality standards in their narrative review. Three measured attitudes, beliefs, norms, and stigma of university students regarding mental health. Results from all three reported some positive impacts of mental health literacy training on these constructs, but the evidence was weak. Amado-Rodríguez et al. (2022) and Nazari et al. (2023) reported that mental health literacy interventions were effective in improving mental health knowledge, but not in reducing stigma 10 Reduction of Mental Health Related Stigma and Discrimination: Global Overview or improving help-seeking behavior. Ma, Burn, and Anderson (2023) concluded that although there is moderate evidence suggesting that school-based mental health interventions can be effective in improving mental health literacy and reducing mental health stigma, there is less evidence for long- term effectiveness. Mills et al. (2023) conducted a meta-analysis of mental health literacy interventions in young people and concluded that there was a medium to large effect size of intervention effectiveness. However, inconsistencies in methodological rigor and reporting need to be addressed, and a more nuanced understanding of effectiveness is needed (for example, teacher versus professional-led interventions or the impact of frequency, duration, and follow-up times). Tam et al. (2024) reviewed mental health awareness campaigns conducted via media and videos on a range of platforms (for example, social media, websites/apps, television, billboards, newspaper ads). Most studies reported positive changes in the attitudes, beliefs, and intentions of young people (for example, reduced stigma) and positive changes in behaviors (for example, increased help-seeking behaviors), with only two showing no significant effects. Future work should extend campaigns to diverse populations and specific mental health concerns, consider cross-cultural validity and cultural competency, ensure audience involvement in development, and tailor interventions to specific platforms. With regard to intervention components, a comprehensive systematic mapping review of interventions with adolescents ages 12–18 found that a combination of education and social contact led to better outcomes than education alone (Patafio et al. 2021). At the same time, effects were higher for education-only interventions if they were delivered in internet and community settings. However, there was a limited number of such interventions, so the results should be interpreted with caution. A review of digital video interventions tested among youth ages 15–25 years found that videos produced better outcomes than lectures or no intervention (Ito-Jaeger et al. 2022). In two of the three studies comparing the digital video interventions to direct contact, no difference was found in attitudes toward people with mental health conditions. Among reviews on young people, LMICs are underrepresented. Hartog et al. (2020) focused on interventions to reduce stigma related to a diversity of health conditions, such as HIV, mental health, leprosy, in LMICs. This review aimed to identify studies targeting children and adolescents, but most included studies target adults given the available literature. The stigma reduction strategies applied most often were community education, followed by individual empowerment of people with lived experience, and social contact within the community, and outcomes were mostly positive. 4.3.2 Family members Nine reviews focused on reducing stigma among family members. A GKT intervention for family and friends of people at risk of suicide (Morton et al. 2021) found positive effects on knowledge, self- efficacy, and gatekeeper-related skills, but the results for stigma and attitudes were inconsistent. Two studies focused on children and youth in families affected by parental mental health conditions. Davies et al. (2022) found that information about hereditary risks of mental health conditions was considered important so that young people do not feel that the conditions experienced by their parents are inevitable for them. Riebschleger et al. (2017) showed that psychoeducation led to decreased stigma and improved family communication about parental mental health conditions. One review reported on mental health literacy interventions among parents, with a focus on mental health conditions that increase in prevalence during adolescence (Kusaka et al. 2022). The review reported significant improvements in mental health knowledge and confidence and/or knowledge in helping children with mental health problems, but no studies found a significant reduction in stigma and/or intention/behavior of helping. Four studies focused on reducing negative attitudes and discriminatory behaviors from family members toward people with a mental health condition. One review identified two original studies that used psychoeducation to reduce stigma within the family in China and Korea (Armijo et al. 2013). Two other reviews concluded that psychoeducation potentially enables caregivers to cope better with 11 Reduction of Mental Health Related Stigma and Discrimination: Global Overview their family members’ mental health condition and reduce stigma (Monnapula-Mazabane and Petersen 2023; Soo et al. 2018). Six reviews showed that disclosure and sharing within families reduced mental health stigma (Adu et al. 2021). Social networking with other families was another strategy which led to stigma reduction. A study in rural China by Ran et al. (2022) reported that an enhanced social contact model was a promising method for reducing stigma among family members. One review focused on increasing empathy among informal caregivers of people with dementia through virtual reality-based simulation interventions (Huang et al. 2024). The qualitative results showed that informal caregivers gained better insight into problems encountered by persons with dementia, but the quantitative evidence was inconsistent. 4.3.3 Health care professionals and students Sixty-eight reviews have been published since 1994 on stigma among health care staff and students. These focused on pre-qualifying stigma reduction programs for trainees, such as nursing and medical students, and in-service programs for qualified staff. More recent reviews have covered community pharmacy staff and students (Crespo-Gonzalez et al. 2023) and physiotherapy professionals and students (Hooblaul, Nadasan, and Oladapo 2023), reflecting the recognition that stigma reduction is important to the provision of good quality care by all professionals. Most (n= 37) addressed mental health conditions generally, eleven focused exclusively on people with dementia (for example, Gkioka et al. 2020; Mulyani, Probosuseno, and Nurjannah 2021), eight on substance use disorders (for example, Bielenberg et al. 2021), five on personality disorders, three on borderline personality disorders (for example , Dicken, Hallett, and Lamont 2016), five on suicidality and self-harm (for example, Saunders et al. 2012), two on intellectual disabilities, one on neurodevelopmental disorders, and one each on psychosis and eating disorders. The stigma-related outcomes included changes in knowledge, attitudes, and clinical skills, as well as clinical confidence and self-efficacy (for example, Ferguson et al. 2018; Maynard 2020). Over time, more studies are using measures of stigma tailored to this target group (Stubbs 2014; van Brakel et al. 2019). Six meta-analyses reported small to medium effect sizes in improved attitudes, a range in effects on knowledge from negligible to large, and medium to large effect sizes in clinical skills (Kolodziej and Johnson 1996; Lien et al. 2021; Petkari et al. 2018; Piot et al. 2020, 2022; Wong et al. 2024). The evidence base for substance use disorder stigma reduction is weaker; one review found that while 12 of 15 studies showed the intervention was associated with statistically small reductions, most studies had a moderate to high risk of bias (Wong et al. 2024). Similarly, a recent review on intellectual disability found only ten studies, out of which only two of these focused on attitudinal change (Hay et al. 2024). A consistent finding is that interventions for health care professionals are more effective when tailored to the professionals' clinical setting and training requirements, for example, by covering specific diagnoses or providing tailor-made contact interventions (Cheung, Chan, and Cheng 2023). Another is that the evidence for improving attitudes is greater for students in clinical settings with patients with less severe conditions who demonstrated recovery (Heim et al. 2019). Two reviews recommend that interventions should be repeated regularly to sustain changes over time (Bte Abd Malik, Kannusamy, and Klanin-Yobas 2012; Wong et al. 2024). Many reviews recommend including people with lived experience in the design and evaluation of stigma interventions in addition to providing contact through live or filmed recovery testimonials, but not all have consistently done so (Brunero, Jeon, and Foster 2012; Classen et al. 2021). Studies reporting multiple kinds of contact (live or filmed) were more often associated with better outcomes on stigma-related knowledge and attitudes than were educational interventions alone (Lien et al. 2021) or interventions with only one form of contact (Knaak, Modgill, and Patten 2014). Two reviews focused on e-interventions for professionals with both reporting improved knowledge and attitudes, more humane treatment of service users, and reduced use of coercive methods (Muirhead et al. 2021; Zubala et al. 2019). Fully online interventions are effective at stigma reduction when they are multi-component including 12 Reduction of Mental Health Related Stigma and Discrimination: Global Overview educational tutorials, case-based instruction, and practice-based learning (Muirhead et al. 2021). Internet-based anti-stigma campaigns have also been reported to reduce stigmatizing attitudes among health care staff (Carrara et al. 2021). The use of digital interventions and simulations, for example, ‘serious games’ or standardized role plays with actors or virtual patients, has increased in part due to COVID-19 pandemic restrictions. In all the studies reviewed, there was a noted benefit of simulations and serious games on stigma reduction (Adewuyi, Morales, and Lindsey 2022; Carrara et al. 2021; Goh, Ow Yong, and Tam 2021; Piot et al. 2020; Rikke Amalie Agergaard, Peter, and Kamilla 2024). A meta-analysis showed a small to medium effect size on learners’ attitudes, and a large effect size on clinical skills at immediate follow-up for simulation interventions, as well as sustained benefits three months later (Piot et al. 2020). A different review reported that staff empathy improved with the narratives of students’ personal experiences, exposure to other individuals with lived experience, and reflective sessions, but did not improve from simulations, suggesting that for students’ direct contact and practice-based components are necessary for more positive effects on stigma reduction (Smyth, Wilson and Searby 2021). Similarly, the authors of a review on virtual reality interventions for health care and other students recommended that while these have potential, they should not be used in isolation and instead be combined with direct contact and education (Szekely et al. 2023). Among students, all interventions targeting dementia showed positive effects in levels of comfort when working with such patients (Alushi, Hammond, and Wood 2015). Evidence suggests that face- to-face experiential learning is more effective than simulated and virtual experiential learning; however, these two approaches have not been directly compared (Adewuyi, Morales, and Lindsey 2022). Interventions were more likely to have positive results if the practice-based experience was preceded by preparatory education. Direct contact without preparation led to feelings of intimidation and inhibition on interacting with people with dementia. For these health care staff and student interventions, the included studies were of variable quality (Brunero, Jeon, and Foster 2012), and few studies have long-term follow-up or reports of clinical behavioral change (Bielenberg et al. 2021; Lien et al. 2021, see also, Brunero, Jeon, and Foster 2012; Gkioka et al. 2020). Few such studies were conducted in LMICs (Caulfield et al. 2019; Keynejad, Spagnolo, and Thornicroft 2021; Liu et al. 2016), with China being the most frequently represented middle-income country (Bielenberg et al. 2021; Lien et al 2021; for example, Hiem et al. 2018, 2019; Piot et al. 2020). It is clear from many studies that greater emphasis is needed for long-term collaborations between LMICs and high-income countries (HICs) for pooling resources and data (Keynejad, Spagnolo, and Thornicroft 2021), assessment of the sustainability of impacts or effectiveness (Carrara et al. 2021), and more cultural adaptations of the anti-stigma programs (Keynejad, Spagnolo, and Thornicroft 2021; Raj 2022). A further key challenge is that not all studies have used well-adapted and validated outcome measures for stigma and discrimination, particularly in LMIC settings (Brohan et al. 2010; Caulfield et al. 2019; Heim et al. 2018; Liu et al. 2016; Magnan et al. 2024; Thornicroft et al. 2019). Researchers recommend more mixed methods with qualitative components (Brunero, Jeon, and Foster 2012). Cost-effectiveness was also a common research gap (Brunero, Jeon, and Foster 2012; Gkioka et al. 2020; Keynejad, Spagnolo, and Thornicroft 2021), as were meta-analyses (Brunero, Jeon, and Foster 2012; Gkioka et al. 2020). 4.3.4 General population Twelve reviews focused on interventions to reduce stigma in the general population, while another three included general population samples in reviews of specific interventions or delivery methods. Corrigan et al. (2012) examined education, social contact, and protest as strategies. Both social contact and education improved attitudes and behavioral intentions, but social contact resulted in significantly greater positive change among adults. In contrast, education yielded a larger effect than contact among children and adolescents. In this review, effect sizes were significantly greater after in-person 13 Reduction of Mental Health Related Stigma and Discrimination: Global Overview contact than after video contact. Two recent reviews have focused on digital interventions. One review on technology-based interventions (online or online plus other modalities) to increase help-seeking found that among those that measured stigma, the majority showed positive outcomes (Johnson, Sanghvi, and Mehrotra 2022). The other covered augmented and virtual reality, ranging from virtual interactions with characters and environments to experiencing perceptual or sensory disturbances related to mental illnesses (Tay, Xie, and Sim 2023). The majority of the studies observed enhancements in knowledge, attitudes, empathy (all studies), and reduced stigma. However, none of the included studies in either review used face-to-face interventions as a control; the results are therefore most applicable to groups and settings in which face-to-face contact is not feasible. Borschmann et al. (2014) evaluated anti-stigma campaigns in 21 European countries. Studies with an evaluation component either found little evidence of significant general stigma reduction effects or variations across different sub-populations. Dumesnil and Verger (2009) examined public awareness campaigns about depression and suicide, which included short media campaigns, GKT programs, and longer programs involving repeated exposures. Their review of 43 studies, showed that public awareness and information programs about suicide or depression improved knowledge and, with only two exceptions, attitudes. Improvements were modest and most often only measured at short term. Two reviews from Australia focused on suicide prevention, one among people living outside of metropolitan areas (rural and regional populations) (Dabkowski et al. 2022) and one reviewing a program for workers in the construction industry which has also been used in other male-dominated industries such as coal mining and the energy sector (Gullestrup et al. 2023). The first of these reviews (Dabkowski et al. 2022) found little evidence for a reduction in suicide stigma although there were other positive outcomes such as reduced use of alcohol and drugs and greater suicide literacy. The authors caution that not all programs reached their intended audience due to an overrepresentation of women. In contrast, the Mates in Construction Programme (MATES) targets men through male- dominated workplaces (Gullestrup et al. 2023). While the authors found some evidence for positive impacts on mental health stigma, they emphasized the need for higher causal inference studies and more emphasis on longer-term outcomes. In other reviews, the authors found that the concurrent use of several strategies, such as distribution of educational material, a media campaign, and training of gatekeepers and health care professionals appeared to be more effective than education alone. Clement et al. (2013) examined the effect of mass-media interventions in the general population and its constituent groups, such as students or employers. Across sixteen studies, five assessed discrimination—of these, one found evidence on reduced discrimination, which was not replicated in two larger similar studies. In a meta-analysis, small to medium size reductions in prejudicial attitudes were found for up to six to nine months follow-up. The clearest pattern of evidence emerged for first- person narratives of people with lived experience and interventions with two or more components, which had greater effects than those with one only. The impact on MHFA trainee behavior and the outcomes of this behavior were the focus of a review that found nine studies examining these outcomes (Forthal et al. 2022). Only three found an increase in use of MHFA skills and none identified an impact on recipients or potential recipients of trainees’ helping behavior. Some studies were underpowered and suffered from attrition; the authors made design recommendations and emphasized the need for rigorous evaluations of MHFA, particularly in LMICs where MHFA research is lacking. Makhmud, Thornicroft, and Gronholm (2022) reviewed studies of indirect social contact interventions in LMICs—of the nine studies from Africa, Asia, and Russia, eight reported positive outcomes covering knowledge, attitudes, and intended behavior. The authors identified a smaller range of media and intervention types as compared to those used in HICs, the need for more information on the interventions, a lack of information on long-term outcomes, and the need for evidence from a wider range of countries especially low-income countries. The evidence on anti-stigma interventions in the general population in China was summarized by Xu et al. (2017a). Their results showed a small and 14 Reduction of Mental Health Related Stigma and Discrimination: Global Overview significant effect on the reduction of negative stereotypes, and that interventions which included social contact were more effective than those which did not. They found no strong evidence that using biological attributions for the cause of mental health conditions improved mental health literacy or reduced prejudice and recommended integrating cultural factors into anti-stigma interventions and measures. Similarly, Mascayano et al. (2020) found that only 20 percent of anti-stigma interventions in LMICs had addressed cultural adaptation, concluding that more careful cultural adaptation is required. In their review of stigma-reduction programs among African Americans, Rivera et al. (2021) concluded that such programs need to be culturally informed and tailored to African Americans. They highlighted the importance of collaboration between mental health providers and faith-based institutions due to mistrust of the medical sector. Scior (2011) reviewed the effect of contact with people with intellectual disabilities, for example in schools or via the Paralympics. As in other reviews, there were limitations such as small unrepresentative samples and cross-sectional designs. However, it appeared that positive contact could reduce desire for social distance, while negative contact experiences could do the opposite. ‘Dementia-friendly communities’ (Hung et al. 2021) have inclusive environmental designs, that is, adaptations to support use of services such as churches and shops. The reviewers found that active involvement of people with dementia provided a sense of value and autonomy. A qualitative study on an intergenerational choir, for example, found that young adults’ involvement reduced their stigma. Hung et al. (2021) also highlighted the need to consider diversity of people with dementia in such communities. The importance of intergenerational contact was echoed in a review by Gerritzen et al. (2020). The use of mainstream recreational facilities (Fenton et al. 2017) to foster social connections, for example, physical or creative activities increased self-esteem and self-confidence and gave people with dementia a sense of accomplishment. 4.3.5 Other target groups Breslin et al. (2022) assessed knowledge-based mental health programs in sport settings (for athletes, coaches, officials, and parents). They reported mixed stigma reduction outcomes, but improvements in mental health knowledge, confidence to help/refer for help, and intentions to seek help. Oostermeijer et al. (2023) reviewed training targeting correctional staff (probation, parole, and custodial officers). Most interventions were educational, with one including contact-based elements, and a meta-analysis of six studies found a small positive effect on stigmatizing attitudes. Future work should include more contact-based approaches and higher-quality trials. Huggins et al. (2022) assessed improving dementia knowledge through educational interventions among racial/ethnic minority groups (mainly in the US, UK, and Australia). Intervention delivery varied from workshops in faith communities to technology (for example, YouTube videos). Many studies reported improvements in knowledge and attitudes, but the overall study methodology was of low quality. Two reviews considered outcomes besides self-stigma of interventions for people living with mental health conditions. Tian et al. (2024) reported that online mental health literacy interventions improved mental health knowledge, attitudes, and self-care skills. In contrast, Jardine, Bowman, and Doherty (2022) examined digital interventions to enhance readiness for psychological therapy, found mixed results, and recommended further qualitative, naturalistic, and longitudinal research. 4.4. Specific intervention components 4.4.1 Advocacy and continuum beliefs Advocacy, and self-advocacy, promote the rights of people with mental health conditions. Methods such as distributing printed materials have been used (Perez-Flores and Cabassa 2021). Findings were mixed for stigma outcomes, with some studies showing reduced stigma toward mental health treatments, beliefs about dangerousness, and social distance, while others have reported no reduction 15 Reduction of Mental Health Related Stigma and Discrimination: Global Overview in stigma toward people who take antidepressants (Perez-Flores and Cabassa 2021). Regarding advocacy programs, one review indicated that its effectiveness in reducing stigma was unknown (Pirkis et al. 2021). Public relations campaigns have been shown to result in stigma reduction for people with depression (Seroalo et al. 2014). One review (Peter et al. 2021) reported that promoting continuum beliefs, that is, that there is a continuum between mental health and mental health conditions (rather than a dichotomous approach), gave mixed results and a few studies even showed increased stigma. 4.4.2. Collaborative Community-Based Care (CCBC) This is defined as any intervention provided by informal community care providers and only implemented in the community, and includes psychoeducation and rehabilitation strategies to improve personal, social, and vocational functioning and links to self-help groups (also known as social networking) and social and financial support (Nguyen et al. 2019). CCBC resulted in greater disclosure by families about their family member's mental health conditions to other people, which was associated with an improvement in their family’s knowledge of schizophrenia and increased social inclusion for people with mental health conditions. It did not, however, reduce the experience of stigma in the people with schizophrenia. Social and financial assistance increased as a result of social inclusion (Nguyen et al. 2019). Community-based mental health care was described as less stigmatizing than hospital care. Social networking led to the normalization of people with mental health conditions (Adu et al. 2021). The use of support networks decreased negative attitudes toward suicide (Takada and Shima 2010). 4.4.3. Gatekeeper training Gatekeeper training (GKT) discusses attitudes and provides knowledge and skills to help gatekeepers (who have direct contact with people at risk of suicide, self-harm, or mental health conditions) better inquire about and recognize the risk for mental health conditions or suicide and to intervene appropriately. Among groups such as students, teachers, social workers, pharmacists, managers, and carers for elderly people, it has been shown to improve knowledge about suicide and suicide prevention and reduce myths about suicide immediately post intervention (Holmes et al. 2021). However, these effects were not sustained 1–12 months later as was also found for GKT with children, adolescents, and teachers (see section 4.3.1). 4.4.4. Protest Protest is a campaign-based approach designed so that a morally unacceptable perspective about a minority group is shown, followed by a reprimand against these practices. They also involve condemnation of media representations of mental illness and societal reaction in general (Griffiths et al. 2014). A review by Griffiths et al. (2014) found that protest campaigns targeting all mental health conditions significantly reduces personal stigma but not internalized stigma or perceived stigma; those targeting a specific mental disorder were more effective in reducing all types of stigma. Another review (Ashton, Gordon, and Reeves 2018) found that protest interventions reduce stigma, but the long-term impact is not clear. Two other reviews (Morgan, Wright, and Reavley 2021; Stuart 2016) concluded that the outcomes of protest campaigns in reducing stigma are unknown. 4.4.5. Psychoeducation This provides information for family members or the public about mental health conditions, including risk factors, prevalence, symptoms, diagnosis, and care, and includes addressing misconceptions and myths. It can be provided face-to-face, through social media, theatre, or workshops. Overall, internet delivery was found to be at least as effective in reducing personal stigma as face-to-face delivery (Griffiths et al. 2014). It is debatable how far educational interventions lead to behavior change. The effect of awareness on help-seeking attitudes and behaviors is inconsistent (Bu et al. 2020; Castaldelli-Maia et al. 2019). One review indicated that psychoeducation for caregivers had 16 Reduction of Mental Health Related Stigma and Discrimination: Global Overview no significant effect on attitudes, empathy, or positive aspects of caregiving compared to controls (Han 2020). However, interventions that included communication strategies may facilitate self-confidence in caregivers, and improved understanding of the needs of the person with a mental health condition (Bacsu et al. 2021; Knaak, Modgill, and Patten 2014). Police officers, teachers, and other public sector workers showed positive changes in behavior on one MHFA review (Booth et al. 2017). However, a meta-analysis of 18 trials with nearly 6,000 participants found minimal positive effects in MHFA course participants’ attitudes (Morgan, Ross and Reavley 2018). 4.4.6. Social contact Social contact (sometimes called ‘contact’ or ‘interpersonal contact’) takes place when there is positive, cooperative interaction between people with lived experience of a mental health condition and a particular target group. Such contact can be direct contact (face-to-face and in-person), or indirect (for example, simulated, video, online, social media, or observed). The types of positive social contact which are likely to be most effective for stigma reduction are characterized by some key factors (Al Ramiah and Hewstone 2013; Knaak, Modgill, and Patten 2014). Contact was found to have consistently positive effects on stigmatizing attitudes, perceived stigma in help-seeking, social distancing (Ashton, Gordon, and Reeves 2018; Clay et al. 2020; Corrigan, Larson, and Michaels 2015; Corrigan, Michaels, and Morris 2015; Doley et al. 2017; Griffiths et al. 2014; Maunder and White 2019; Morgan et al. 2018; Peter et al. 2021; Schreiber and Mc Enany 2015), social interaction, fear (Zhang et al. 2019), discrimination (Schreiber and Mc Enany 2015), and coercive behavioral intentions (Corrigan, Michaels, and Morris 2015). At the population level (Thornicroft et al. 2016) and for specific groups such as students, contact-based interventions usually achieve attitudinal improvements but less often knowledge gain. A combination of interventions (particularly of education and contact) significantly reduces stigmatizing attitudes and social distance (Hawke, Parikh, and Michalak 2013; Mascayano et al. 2020; Morgan, Wright, and Reavley 2021; Morgan et al. 2018) and is superior to traditional educational approaches. Interventions directly involving people with lived experience were more effective in reducing stigma compared to studies that did not (Clay et al. 2020; Corrigan, Michaels, and Morris 2015; Ren et al. 2020; Seroalo et al. 2014). No significant difference in effectiveness was found between different delivery modalities of contact, such as face-to-face, imagined, or video, in reducing stigma (Maunder and White 2019). Social contact through theatre or film has been shown to produce improved knowledge and attitudes toward people with mental health conditions and to address misconceptions (Bacsu et al. 2021; Dalky 2012; Doley et al. 2017; Hawke, Parikh, and Michalak 2013; Mascayano et al. 2020; Matsumoto et al. 2023), as well as lead to sustainable behavioral changes (Dalky 2012; Doley et al. 2017). Active interaction with people with lived experience as they described their life experiences was more effective than passive interaction. Greater reduction in stigma was seen for health care professionals compared to non-professionals (Ren et al. 2020). 4.4.7. Simulated symptoms Simulation has been used to demonstrate the experience of auditory hallucinations, using audio segments of voice and non-voice sounds with derogatory and neutral/benevolent content, to increase empathy and understanding of such symptoms (Ando et al. 2011; Griffiths et al. 2014). While it can increase empathy for people with schizophrenia, the evidence of effectiveness on attitudes is inconsistent, and some studies indicate that it may worsen attitudes and desire for social distance (Morgan et al. 2018). 4.5. Self-stigma Thirty-four reviews were included on interventions for self-stigma, all published during 2012–2024. Fifteen were on interventions specifically designed to address self-stigma (Alonso, Guillen, and Munoz 2019; Bannatyne et al. 2023; Büchter and Messer 2017; Jagan et al. 2023; Klein et al. 2023; Larkings 17 Reduction of Mental Health Related Stigma and Discrimination: Global Overview and Brown 2018; Mills et al. 2020; Mittal et al. 2012; Rüsch and Kösters 2021; Sibley, Colston, and Go 2024; Sun et al. 2022; Tsang et al. 2016; Wood et al. 2016; Xu et al. 2017b; Yanos et al. 2015). Eighteen studies were of interventions targeting other primary outcomes and included self-stigma or other related measures. Of the specific self-stigma studies, some reviews included people with any mental health condition (Rüsch and Kösters 2021) or people exposed to traumatic life events (Mittal et al. 2012). Four (Sun et al. 2022; Tsang et al. 2016; Wood et al. 2016; Yanos et al. 2015) included only studies on people with severe mental health conditions, one on people who use drugs (Sibley, Colston, and Go 2024), and one on medical students or doctors (Bannatyne et al. 2023). In general, the reviews included studies which reported either an improvement in self-stigma, or in a similar outcome such as stigma stress or self-efficacy in the absence of a positive result for self-stigma. One review (Larkings and Brown 2018), however, found evidence from six studies (both experimental and observational) of a relationship between the endorsement of biogenetic causes of mental health conditions and worse stigma outcomes, namely greater pessimism about prognosis and recovery. Two reviews with meta-analysis found that the improvements for self-stigma became nonsignificant over time (Büchter and Messer 2017; Wood et al. 2016); the exceptions are Narrative Enhancement and Cognitive Therapy (NECT) (Jagan et al. 2023) and the Honest, Open, Proud (HOP) intervention (Klein et al. 2023; Rüsch and Kösters 2021). A meta-regression of HOP RCTs suggests that people less burdened by shame about their illness benefit more and the positive outcomes at three to four weeks on self-stigma, depression, and quality of life were positively influenced by reduced stigma stress at initial follow-up (Klein et al. 2023). For people with schizophrenia spectrum disorders, there are now sufficient trials to allow meta- analysis of the results for each of group’s psychoeducation and NECT (Jagan et al. 2023). The summary effect for psychoeducation was nonsignificant and this analysis was affected by high levels of heterogeneity; in contrast, the summary positive effect for NECT was significant and heterogeneity was much less. These authors also point out that among the most effective interventions were those that combined therapies such as psychoeducation, cognitive behavioral therapy, social skills training, mindfulness, problem-solving skills, communication skills, and support groups. One review that focused on people who use drugs found 15 studies: eight used a psychotherapeutic approach, five used psychoeducation, and two used multiple components (Sibley, Colston, and Go 2024). The results did not allow any specific approach to be recommended; instead, the authors recommend improvements in measurement, adaptation, and trialing of NECT, and delivery outside of clinical settings including online, as most people using drugs are not engaged in treatment. Büchter and Messer (2017) recommended differentiation of interventions for groups with different needs, for example, people experiencing intersectional stigma related to gender, ethnicity, or employment status. This and another review (Wood et al. 2016) question the responsiveness to change and validity of outcome measures used. Only two reviews focused on LMICs. Xu et al. (2017b) examined people with lived experience of any mental health condition in mainland China; Hong Kong SAR, China; Taiwan, China; and Macau SAR, China. Demissie et al. (2018) focused on people with lived experience of bipolar disorder in LMICs. Both reviews found positive effects of psychoeducation on self-stigma, self-prejudice, and coping with stigma. Most self-stigma interventions are delivered to groups, a barrier for people unwilling to disclose a mental health condition (Jagan et al. 2023). The potential for many recovery-oriented interventions to reduce self-stigma was highlighted by Winsper et al. (2020). They found that self-stigma was rarely measured; the 18 reviews including at least some studies that measured self-stigma covered interventions that are widely accessible, such as psychoeducation (Demissie et al. 2018; Luo et al. 2022); do not require group attendance, such as peer support (Evans et al. 2023; Orock and Nicette 2021) or digital interventions (Abtahi et al. 2023); target help-seeking (Aguirre Velasco et al. 2020; Mills et al. 2020); or investigate other outcomes, for example, symptom reduction (Musiat and Tarrier 2014), 18 Reduction of Mental Health Related Stigma and Discrimination: Global Overview musicianship (Solli, Rolvsjord, and Borg 2013), advocacy (Weetch, O'Dwyer, and Clare 2021), or employment (Winsper et al. 2020). Aguirre Velasco et al. (2020) reviewed largely school-based interventions for adolescents, finding some improvements in help-seeking intentions, or stigma related to help-seeking, though the study quality was rather low. A clear learning is the need to assess interventions outside health care, for example, social marketing campaigns (Abtahi et al. 2023). 4.6. Cost-effectiveness Although campaigns to reduce mental health-related stigma and discrimination need to be assessed for their cost-effectiveness to assess value for money and return on investment, no reviews were found that specifically evaluated this. There are, however, several original studies which are relevant. In California, one initiative aimed to increase help-seeking by reducing stigma (Ashwood et al. 2017) and found that for each US$1 spent, there could be US$1,251 benefits through increased employment because of improved health. Benefits to the state government were estimated at US$36 for each US$1 spent on the campaign. One modelling study to assess the cost-effectiveness of the TTC anti-stigma campaign in England estimated that the campaign cost per person with improved intended behavior was £4 (Evans-Lacko et al. 2013). In Germany, the HOP program for adolescents with mental health conditions has been subjected to a health economic analysis, which found that it is likely to be cost- effective (Mulfinger et al. 2018). The evidence which is available tends to suggest that such interventions may be cost-effective at the program and population levels. 19 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 5. OVERVIEW OF CASE STUDIES OF NATIONAL-LEVEL ANTI-STIGMA PROGRAMS For over 25 years, a series of large-scale programs have been delivered to reduce stigma and discrimination in different countries and regions across the world. Here a series of these programs is presented, with an emphasis on programs in East and Southeast Asia, selected to show the diversity of settings and interventions, to bring the principles and evidence of stigma reduction vividly to life through actual practical experience (Table 1). Stigma and discrimination still appear to be one of the most neglected aspects of mental health. As these case studies show, in some countries there had been a significant shift with the transformation of mental health policy leading to the welcome transformation of services from institution-based care to community-based care and support. However, the need to educate the community and transform attitudes, to create more supportive and inclusive communities and ultimately support recovery beyond the provision of treatment of symptoms, is often overlooked. The COVID-19 era has increased awareness of the need for programs that challenge stigma and support earlier help-seeking and self-care and government funding has been secured in many parts of the world. Motivations for establishing and funding these programs differed—from taking a human rights perspective to a focus on mental health promotion and prevention. Most of the case study programs have adapted global evidence-based methods and contextualized them with many positive impacts reported, and much learning to share. Most of the stigma programs have clear outcomes, targets, and target audiences. Some core components included social contact, lived experience champions/ambassadors to share their mental health experiences at social contact events and online, social marketing campaigns, targeted programs with health care professionals, employers, schools, universities and youth audiences, and the media. For a small number of programs, lived experience leadership was central and instrumental to all aspects from governance to design and delivery but this not true for all programs—many have some involvement of people with lived experience of mental health conditions, for example, in project steering groups at different operational levels. It has been established that changing behaviors need long-term sustained efforts. There were many examples of programs sustained for more than a generation (New Zealand, Scotland) and for a generation (England, Canada, and the Czech Republic). The work in England ended when the government funding was not renewed after 15 years, showing that programs are vulnerable to changes in governmental priorities. However, in England the majority of the local work has continued to be funded and employers, schools, the media, and sports groups have continued to focus on mental health and addressing stigma including on national television channels. 20 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Table 1. Overview of case studies of national level anti-stigma programs Program: Name, Implementation Target Audiences Location Program Overview Budget/Funding Outcomes Impact Data Dates and Methods Scale Time to Change A partnership of the mental 2007–2021 Budget: Annual average National Level Target Audiences: 12.7% Improvement in public (TTC) program, health NGOs Mind and Rethink £4–5 million. Improvement in • Adults aged 24–44 attitudes (2008–2021) Mental Illness. King’s College England London (KCL) was the evaluation Funders: The National • Public mental health (subconscious stigmatizers) 12% Improvement in reported and Lottery and Comic Relief knowledge • Men ages 24–44 (little intended behavior (2009–2020) National, Regional, partner. (2007–2011). UK • Public attitudes understanding of mental 15% Decrease in average levels of Local Longest running evidence-based Government • Public reported and health and lower socio- discrimination (2008–2014) national program to address (Department of Health intended behavior demographic groups) Significant improvement in local and mental health stigma and & Social Care) and Comic • Experienced • Children and young people national print media coverage (2008– discrimination in England and is Relief (2011–2021). discrimination (11–16) and their parents 2016). one of the most researched in the Supplementary funding • Media mental health world. Voted in the Top 20 public from the Department of • African and Caribbean adults Increased anti-stigmatizing articles coverage (31% to 50%) decreased stigmatizing health achievements of the 21st Education (for the ages 24–44 • Levels of confidence to articles (46% to 35%) century by UK public health Children & Young People • • South Asian adults (pilot) tackle stigma among experts. Campaign), the Premier • 61% of trained champions in 2018 felt trained lived experience • Employers (3,000) TTC built a social movement of all League, McVitie’s (for increased confidence to challenge • champions. • Schools (2,000) sectors and with lived experience Time To Talk Day) and stigma and discrimination. in program governance, Ford cars (male-focused • Media companies management, design, delivery and campaign). • Mental health professionals impact evaluation. (pilot) • Primary care professionals (pilot). Main Methods: • Social contact (60+ local projects) • Lived experience champions • Training and support • Social marketing • Digital owned channels (for example, 275,000 followers on X). 21 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Program: Name, Implementation Target Audiences Location Program Overview Budget/Funding Outcomes Impact Data Dates and Methods Scale Nōku te Ao o Health New Zealand | Te Whatu 1997–present Budget: Information not Overall outcome aims for Target Audiences: • Increased engagement among program Ora program managed by the available the program Benefit group is particularly Māori those from Māori and Pacific Health Promotion Directorate. communities participating in (previously called Delivery via organizations Funder: Health New 1. Equitable treatment by and Pacific peoples. Also, projects program Zealand | Te Whatu Ora the government and tackling equity issues for disabled Like Minds, Like including Māori Public Health society through law, and rainbow communities. • Social media engagement Mine), New Organisation, Mental Health policy, and norms. Target audience are those where • Grants are funding community- Zealand Foundation, a tertiary institute, 2. Fair structures in people experience discrimination led projects engaging thousands and community-based National, Local organizations, including (health care settings, across multiple online and offline organizations. Evaluation values, policies, and whānau/family and friends) as well engagements undertaken by a research procedures. as settings that influence culture subsidiary of a tertiary institute. • Improved public attitudes to 3. Positive portrayals in change (for example, media). The world’s longest-running people with severe mental public communications, Main Methods: distress stigma and discrimination including media, arts, • program contributed to Social Action Grants for • Reduced discrimination and academia. individuals and community significant improvements in experienced among people with public attitudes and reductions in 4. Inclusive behaviors in groups to tackle mental distress (in 2014 over half discrimination. The Like Minds, personal interactions discrimination of the 1,135 people who recently Like Mine program had a high- with whānau (family), • A community engagement used mental health services profile impactful advertising friends, and other arm to mobilize lived reported less discrimination than campaign featuring famous and contacts. experience at the grassroots during 2009–2014). everyday people. 5. Influential role- to challenge systemic The focus of the new Nōku te Ao modelling by people discrimination through program is to work with and for with experience of advocacy, policy engagement, the people most affected by mental distress in all storytelling, and media discrimination including Māori parts of society. engagement and Pacific communities. It is a • Seeing improvements in • Education/training for those multilevel program based on all spaces but still working with mental health indigenous kaupapa Māori building momentum. service users principles with local activities. • Media grants, monitoring, training and engagement • Research projects and symposiums • Program evaluation. 22 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Program: Name, Implementation Target Audiences Location Program Overview Budget/Funding Outcomes Impact Data Dates and Methods Scale batyr program, batyr is the lead agency (an 2011–present Budget: Organizational Linked to program activity Target Audience: • 70% of young people who Australia Australian preventative mental expenditure in 2020 (not (pre, immediately post, and • Young people (14–30 and experienced a batyr education health NGO) driven by young all stigma-focused) AUD at three-month follow-up) communities that support program reported being more National, Local people, for young people 7.5 million. • Help-seeking behavioral them. likely to reach out for support if founded in 2011. It recently Funders: Corporate intentions they need it (compared to 22% developed an organizational Main Methods: sponsors, donations, of general Australians) theory of change and evaluation • Attitudes related to the • ‘Being Herd’ program. 1,200 government funds, and stigma of mental health • Reduced stigma, increased framework in collaboration with fees for services. young people (18–30) trained attitudes and intentions to seek The Centre for Social Impact. • Improved awareness of to share lived experience in professional mental health care Works with a wide range of mental health literacy schools and universities. among 500 students in 2017 partners (400+ schools and 25 • Increased skills and • ‘OurHerd’ app. digital (maintained at three-month universities) delivering evidence- confidence to talk storytelling platform/app for follow-up) based programs to reduce stigma about mental health. young people to share lived • Increased help-seeking for and empower young people to experience. Moderated, personal, emotional, and mental reach out for support. sentiment analysis, AI, and health from 30% to 65% in 2023 Activity is driven by young people machine learning to capture with a link between the sharing lived experience (the data. batyr@school program and ‘Being Herd’ program trains young • Mental health educational lower levels of stigma. Sharing people to share their mental workshops in schools, lived experiences was the most health experiences), contact- universities, workplaces useful aspect of the program. based interventions, mental • Schools (500 secondary health literacy training, and peer schools) engagement. • Campaigns. Multimedia channel campaign • Lived experience involvement. Young people including those with lived experience at the center of the organization and all activity 23 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Program: Name, Implementation Target Audiences Location Program Overview Budget/Funding Outcomes Impact Data Dates and Methods Scale Time to Change A partnership of UK mental health 2018–2020 Budget: £1.7 million (2 • Public Attitudes among Target Audiences: Evaluation of the social marketing Global program, NGOs Mind and Rethink and (program closed years) target audiences (CAMI) • General public—specific campaigns in Ghana and Kenya: international NGO Christian Funders: UK Government • target audiences of young • Africa and India Blindness Mission (CBM) working when funding Mental health people or adults MAKS - statistically significant ended but the (Foreign, Commonwealth knowledge among improvement in Nairobi Local (pilots) and with five NGO partners in Africa Kenyan project and Development Office, target audiences in • Local people with lived and Southern India and 111 • RIBS - statistically significant Global Toolkit ran until 2023) FCDO) and Comic Relief Ghana and Kenya experience (to become people with lived experience improvement in Ghana. The assessed by MAKS with ‘champions’ and train to share trained as champions. estimate for the magnitude of two additional lived experiences) this change is the same as TTC Champions shared their questions added Main Methods: England for the general experiences at social contact relating to beliefs that • Research. Qualitative population between 2009 and events and as part of social mental illness is a curse audience insight research 2019, a promising result for a marketing campaigns to improve and is genetically linked with local populations in each short-term public mental health public knowledge, attitudes, and community and with local • Public behavioral campaign. intended behavior using the champions. intentions amongst target audiences (RIBS). • adapted core methodology of TTC. Training. Capacity-building A Global Anti-Stigma Toolkit training and support for shared tools and experiences of project leads. partners and lived experience • Social contact training and champions. An evaluation of the events. Training and support social marketing campaigns in for champions to safely and Nairobi, Kenya and Accra, Ghana effectively share their by KCL was published in 2021. experiences at social contact events and in campaigns. • Social marketing campaigns. • Co-production of a global anti-stigma toolkit https://tinyurl.com/4tv9ttaf • Global anti-stigma summit. 24 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Program: Name, Implementation Target Audiences Location Program Overview Budget/Funding Outcomes Impact Data Dates and Methods Scale Understanding The program is a partnership 2021–present Budget: Information not Among health care Target audience: • Significant improvements in all Stigma and between PAHO and the Mental available professionals receiving the Primary health care professionals measures of confidence and Health Commission of Canada. Funded by PAHO and the training, comfort in the overall quality of Strengthening in the Caribbean mental health care they provided An online training program in the Mental Health • Health care Cognitive Caribbean to improve primary Commission of Canada professionals’ Main methods: to clients. Behavioral health care professionals’ ‘Opening Minds’ Anti- confidence in the The training program has two core • Stigmatization was reduced. The elements: Interpersonal confidence in the quality of Stigma Initiative quality of the mental Stigma Scale showed Skills program, mental health care they provide health care they • Online stigma-reduction statistically significant and reduce their levels of stigma. provided component to help improvement in scores with a World Health professionals recognize their Research had shown the core • medium effect size on two of the Organization Changes in stigma own stigmatizing attitudes Opening Minds Stigma Scale for barriers to changing practices in among health care staff (WHO) Caribbean mental health care were the need (Opening Minds’ Stigma and behaviors, their impacts, Health Care Providers (OMS-HC) region to strengthen providers' capacity Scale for Health Care how they present in primary subscales. care, using videos of personal through knowledge and skills and Providers). National, Regional stories. address factors that impede motivation to change. Health care • The second element is the providers' stigmatization was also Cognitive Behavioral an important barrier to treatment Interpersonal Skills that are in the Caribbean. delivered virtually and designed to increase providers' confidence to help clients recover and reduce stigmatization. 25 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Program: Name, Implementation Target Audiences Location Program Overview Budget/Funding Outcomes Impact Data Dates and Methods Scale NA ROVINU (On The program is led by the National 2017–present Budget: 2017–2022 CZK National-level Target Audiences: At national population level: the Level) Institute of Mental Health, 94.96 million CZK (£3.3 improvements: • People with lived experience • Improvement in public attitudes Czechia (NIMH CZ). million) • program, Czech Public attitudes • Families of people with lived with attribution to the campaign In 2013, the Minister of Health Funder: Ministry of • (2013–2019) Republic approved a strategy of mental Social Affairs (sourced Intended behavior experience • Self-stigma (people • Social workers • Public intended behavior. No National, Regional health care reform. The first from European Structural change (2013–2019). phase (2013–2021) included goals Investment Funds) with lived • Public administration of reducing self-stigma and experience) workers reducing discrimination based on • Communities stigmatizing attitudes from health care staff, social workers, and • Health care professionals others. (General Practitioners, emergency services staff, staff The NA ROVINU program started in general hospitals). in 2017 with a focus on addressing mental health stigma and Main Methods: discrimination and is now more • Training and support for focused on prevention and mental people with lived health literacy. experience—to share their experiences as part of delivery • Six toolkits designed for each target audience • Campaigns and communication • Lived experience involvement was a central aspect of the program from design to delivery and evaluation. 26 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Program: Name, Implementation Target Audiences Location Program Overview Budget/Funding Outcomes Impact Data Dates and Methods Scale Working Minds The Mental Health Commission Opening Minds Budget: Information not • Reductions in stigma Target Audiences: The Working Mind was associated program, Canada of Canada oversees the program. (2009–present) available • Increases in resilience • Employers/the workforce with The Opening Minds anti-stigma The Working Mind Funder: Self-sustaining • Overall mental health including special adaptations • Moderate reductions in stigma National training program was set up in (2013–present) and funded through its for specific groups such as literacy improved • Moderate increases in self- 2009, with the Working Mind workplace training first responders, health care reported resilience and coping aspect of this program now a programs. • Overall mental wellness providers, construction improved. ability. separate entity that re-invests workers, and so on. profits from the income of its Both maintained at the three-month Main Methods: follow-up. workplace delivery back into anti- stigma work and the Commission. • Training to reduce stigma and promote mental health in the workplace, creating a more resilient and supportive culture among employees and leaders. It is structured into four interactive modules with videos, case studies, and practical exercises. These cover Mental Health and Stigma, The Mental Health Continuum, Coping Strategies, and a fourth module for Managers ‘Supporting Your Team’. The courses are offered in person or virtually. 27 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Program: Name, Implementation Target Audiences Location Program Overview Budget/Funding Outcomes Impact Data Dates and Methods Scale More Than a Label The program is an initiative of 2019–present Budget: Annual average • Public attitudes. Survey Target Audiences: Among a sample of public who program, Hong Mind Hong Kong (Mind HK). (funding secured HKD 1.5 million of 1,010 adults to assess • Hong Kong residents (adults, viewed campaign videos, until 2025) (approximately attitudes conducted by • Kong The pilot anti-stigma program £150,000) Social Policy Research mostly working age) Significant positive started in 2019 with initial funding • Health care providers improvement in attitudes and National from a Hong Kong Foundation, Funders: MINDSET Ltd. intended behavior but not Main Methods: followed by the program launch in (Jardine Matheson • Public mental health mental health knowledge as a 2021. The Hong Kong Government Group Charity) • Ambassadors. 122 local total score knowledge funds its own campaign which is people with lived experience • Public reported and provided with bilingual • Positive improvement in stigma not linked to this program. intended behavior scores in a survey of general and training and ongoing support • Stigma among health to safely and effectively share mental health nurses after care providers. Using their mental health ambassadors had shared their OMS-HC tool in pre and experiences in public (social stories post surveys, following contact events, online, in • Improved healing and self- ambassador-sharing campaigns). discovery among ambassadors. session. • Community events (using Three themes emerged: “the social contact). 100+ events impact goes both ways” with in public settings, workplaces, sharing lived experience, the schools importance of the supportive community of peer • Social marketing campaign. ambassadors, and the support Large-scale annual campaign from Mind HK. • Owned social media channels. 4,000 followers on Instagram and 31,191 views of campaign videos • Stakeholder engagement. Extending reach to a wide range of communities Mental Health The Mental Health Supporter Pilot 2020–2023 Budget: Information not Primary Outcome: Target Audience: Study among Japanese people trained Supporter Training Training Program was led by the National upscale available • Japanese version of the • Adult residents in Japan (no between October 2022 and February National Institute of Mental 2023 across 18 municipalities. Pre (T1) program, Japan Health between 2020 and 2023. 2024–2033 (across Funder: Ministry of Reported and Intended exclusion criteria) and immediately post training 1,700 Health Behavior Scale (RIBS-J) Main Methods: National via Regions From 2024, a private contractor is municipalities assessments (T2) and approximately six delivering a national program of with a target of 1 • Face-to-face or online months later (T3): training in large-scale and Secondary Outcomes: training for two hours to • Despite the mean intended middle-scale cities, with a target help participants better behavior score increasing 28 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Program: Name, Implementation Target Audiences Location Program Overview Budget/Funding Outcomes Impact Data Dates and Methods Scale of training 1 million people as million people • Japanese Version of the understand mental illness significantly between T1 and T2, it ‘Cocoro Supporters’ by 2033. trained by 2033). Mental Health Literacy and learn about support returned to the baseline level at The program is a Japanese Scale (MHLS) techniques for people with T3 showing no longer-term adaption of the MHFA program • Psychological distress mental health difficulties effect. The mean reported and was first rolled out to 7,000 using the Kessler close to them. There are two behavior score increased and adults (average age 44). It is a Psychological Distress additional modules that can remained the same at T3 but the two-hour online training course to Scale 6 (K6) (based on be chosen: Self-care through effect size was small. help participants better the premise that coping with stress and • The scores for Mental Health understand mental illness and listening to people Learning about mental Literacy increased from T1 to T2 learn about support techniques around them may illness. at significant levels for both for people with mental health reduce interpersonal knowledge and attitudes and difficulties close to them. conflict and improve remained the same at T3. their own mental • Mental health knowledge score health) increased at significant levels • Mental health from T1 to T2 and remained the knowledge. same at T3. • The Psychological distress score showed a small but significant change at T3. (*) 2024 update: Findings in a new paper (the purpose of which was to modify the program evaluated in the previous study and verify its effectiveness for participants in the FY2023 program), “suggested that the combination of educational and contact-based interventions might reduce public stigma toward people with mental health problems immediately post intervention, an effect that persists 3 months later.” Beyond the Label The national Beyond the Label Phase 1: 2018– Budget: SGD 2 million • Public Attitudes Target Audiences: From the public survey, those who program, (BTL) movement was initiated and 2021 SGD or £1.2 million per • Public Mental Health • Families and caregivers were BTL-aware were funded by the National Council of year. • Singapore Social Service (NCSS) and is now a Phase 2: 2022– Knowledge • Children and young people 12.8% higher on the attitude 2028 • Public Behavior scale collective impact initiative co-led 29 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Program: Name, Implementation Target Audiences Location Program Overview Budget/Funding Outcomes Impact Data Dates and Methods Scale National by TOUCH Community Services. Funders: Government, Assessed via a survey of • Communities • 22.6% higher on the mental The ‘BTL Collective’ is a national corporate sponsors, 2,000 adults that also asks • Employers health knowledge scale movement with many public, trusts, donations. about the BTL campaign and • 7.3% higher on the behavior voluntary and private sector showing influence of the Main Methods: scale. agencies and stakeholders campaign. • The BTL Collective—34 involved. The movement’s Scales used include agencies from the public, primary focus is addressing Community Attitudes toward private, and people sectors stigma and promoting social the Mentally Ill (CAMI-12) adding leverage and reach inclusion for people with mental Scale, Reported and • Social marketing campaign. health conditions. Intended Behavior Scale Let’s Get Talking—The aim (RIBS), and Mental Health of the latest campaign is to Knowledge Schedule (MAKS). encourage persons with mental health conditions to share their stories of strength and resilience, and to seek help early. • Community engagement— Events roadshows, talks/ workshops and a grant for the BTL workgroups to implement their initiatives. • Ambassadors with lived experience who share their stories with the public to inspire others facing similar struggles to speak up and seek help. In the public survey, for the most negative architype (22%) the lack of contact was an issue. • Beyond the Label chatbot ‘Belle’—For people or their families/friends struggling with stress or anxiety, which is now also available via WhatsApp and online. Belle 30 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Program: Name, Implementation Target Audiences Location Program Overview Budget/Funding Outcomes Impact Data Dates and Methods Scale will be consolidated with Mindline.sg, a digital first- stop touchpoint for mental health resources and support from January 1, 2025. Current users of Belle will be directed to Mindline.sg, where they can access a self-assessment tool that allows users to be directed to relevant mental health resources and services. • Workplace—Employer Pledge and Resources panel dialogue/ workshops, targeted campaign. • Higher education— Roadshows in institutes of higher learning. • Schools—Psychoeducation talks. • BTL Plug and Play Kit. A toolkit offering a wide range of activities for young people with resources and tips for launching their own anti- stigma initiatives. 31 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 6. CONCLUSIONS AND RECOMMENDATIONS This policy note demonstrates that there is now strong evidence about how to reduce stigma and discrimination in the field of mental health. A failure to act on this evidence would mean the continuation of heavy adverse impacts on individuals, families, communities, and societies. Therefore, the time to act to eradicate mental health-related stigma and discrimination is now. This briefing note also makes it clear that programs to reduce stigma and discrimination need to be carefully adapted, taking into account cultural factors and cultural differences. The WHO Comprehensive Mental Health Action Plan 2013–2030 makes clear that, “The vision of the action plan is a world in which mental health is valued, promoted and protected, mental health conditions are prevented and persons affected by these conditions are able to exercise the full range of human rights and to access high quality, culturally-appropriate health and social care in a timely way to promote recovery, in order to attain the highest possible level of health and participate fully in society and at work, free from stigmatization and discrimination” (WHO 2019). The following recommendations are proposed. 1. The creation of plans to fund, implement, and evaluate long-term programs to reduce mental health stigma and discrimination. 2. The central component of these plans is to use the evidence-based active ingredient of social contact for stigma reduction. 3. People with a full range of mental health conditions, including more severe conditions, need to actively contribute to these plans by co-leading the design, delivery and evaluation of the programs. 4. Specific target audiences and outcomes need to be identified at the outset of each program. 5. The programs operate with widespread cross-sectoral support and participation, for example with the industry, sports, music, television, film, health care, and educational sectors. 6. A detailed evaluation of impacts and outcomes is conducted for each program, compared with an initial baseline assessment of key metrics. 32 Reduction of Mental Health Related Stigma and Discrimination: Global Overview APPENDIX 1. REFERENCES Abtahi, Z., M. Potocky, Z. Eizadyar, S. L. Burke, and N. M. Fava. 2023. “Digital Interventions for the Mental Health and Well-Being of International Migrants: A Systematic Review.” Research on Social Work Practice 33 (5): 518–29. Adewuyi, M., K. Morales, and A. 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DETAILED CASE STUDIES OF NATIONAL ANTI-STIGMA PROGRAMS 1. ‘Time to Change’ program, England Time to Change (TTC) in England was the longest running evidence-based national program to address mental health stigma and discrimination (2007–2021) and one of the most researched in the world. It is listed as one of the top 20 public health achievements of the 21st century by public health experts voting in the United Kingdom Royal Society for Public Health poll in 2019. TTC built a social movement to improve levels of public mental health knowledge, attitudes, and intended behavior and reduce levels of mental health discrimination. It measured improved confidence and skills to tackle stigma among lived experience champions. Central to the whole program is the direct inclusion of people with lived experience in program governance, management, design, delivery, and impact evaluation. Program overview Time span 2007–2021 Scale National outcomes with national, regional, and local delivery The funding received was £4–5 million each year. The national Lottery and Comic Relief funded phase 1. Funding for phase 2 was secured from the UK government (Health and Education ministries). Supplementary funding was received from Funding the football Premier League, Sport Relief, and corporate sponsors with tea and biscuit manufacturers sponsoring Time to Talk Day and funding their male- focused campaign in partnership with TTC. TTC was a partnership of the English mental health NGOs Mind and Rethink Mental Illness, with a lived-experience-led NGO which was also a partner in the first phase of the program. KCL was the evaluation partner. There were many local organizations involved in delivering social contact events with the Partners establishment of local TTC coordinating hubs. Market research agencies were commissioned to undertake audience-insight research, evaluation of each campaign burst, and undertake strategic reviews of audiences and impact. Advertising agencies were selected for creative design and media planning of social marketing campaigns across media platforms. TTC was, in part, inspired by the ‘Like Minds, Like Mine’ program in New Zealand Model and (now called Nōku te Ao) and ‘See Me’ in Scotland. Lived experience leadership evidence base and the recognition of social contact as the core activity developed within the first two years of the program. 47 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Implementation For the national social marketing campaign, • Audience-insight research informed the selection of the primary campaign target audience of adults ages 24–44 (subconscious stigmatizers) (2007– 2011) Target • Target audience of children and young people ages 11–16 and their parents audiences (2011–2021) • African and Caribbean adults ages 24–44 • South Asian adults • After a strategic review, the new primary target audience in the final third phase (2016-2021) was men ages 24–44 from lower socio-demographic groups, with relatively little understanding of mental health. • National social marketing campaign • Children and young people program—social marketing aimed at children and parents, trained young champions, whole-school approach with over 2,000 secondary schools and head teachers’ network • Champions—trained and supported over 7,000 adults across England and developed champions groups providing ‘support’ as campaign peers • Social contact—events across all regions in England with £3 million funding for local social contact projects with teams of trained champions and regional coordinator to support Project • Employers—supported 3,000+ employers develop action plans and pledges activities/ • Digital—owned channels, supported the online movement methods • Media engagement—supported the media with 80 scripts of TV/radio dramas/soap operas each year • Two pilot training programs: health staff, police, and for primary care professionals • Central management—program management, evaluation manager, digital, communications, celebrity liaison • Lived experience involvement. Lived Experience Advisory Panel to provide lived experience at all levels: governance, program management, project delivery, campaign advisory group, and evaluation. Delivery team • Total of 60 staff, including management, communications, evaluation and projects. Outcomes National-scale evaluations and media coverage analysis was carried out by the Institute of Psychiatry, Psychology and Neuroscience (IOPPN), KCL, and other research bodies were commissioned for project evaluations related to employers, schools, mental health professionals, and primary care providers. Further research was undertaken through in-house analysis of people with lived Evaluation experience on the extent and impact of stigma (‘Stigma Shout’). The evaluation tools tools used were public knowledge - Mental Health Knowledge Scale (MAKS) (Evans-Lacko et al. 2009); public attitudes - Community Attitudes on Mental Illness scale (CAMI) (Taylor and Dear 1981); public levels of reported and intended stigma-related behavior (RIBS) (Evans-Lacko et al. 2011); experienced discrimination (Discrimination and Stigma Scale, DISC) (Brohan et al. 2013); and improvement in confidence to tackle stigma among trained champions. The program also evaluated media coverage of mental health issues. 48 Reduction of Mental Health Related Stigma and Discrimination: Global Overview • 12.7 percent improvement in public attitudes since the start of TTC (2008– 2021) • 12 percent improvement in reported and intended behavior (RIBS 2009– 2020) • 15 percent decrease in the average level of discrimination (2008–2014) • 61 percent trained champions, feeling more confident to challenge stigma and discrimination (2018) Evidence of • Significant improvement in local and national print media coverage of effectiveness mental health for 2008–2016. • Significant increase of anti-stigmatizing articles (31–50 percent). • Significant decrease in stigmatizing articles (46–35 percent). • Over 50 outcome papers published by KCL (see for example, Henderson and Thornicroft 2009a, 2009b, 2013; Henderson et al. 2014, 2016). • The final impact report is available on request. • A film to mark the achievement of the 15-year program is available at https://youtu.be/p1fcPcnLQ3I. Cost- effectiveness/ In all campaign cost–success rate combinations the return on investment is well Economic above 1. Even with the worst scenario with a campaign cost of £2 million and a 1 evaluation percent success rate, the return is eight times the investment. Lessons learned and recommendations • This is the work of a generation—long-term, sustained approaches are required. • If national-scale change is the ambition, then national audience-insight-informed campaigns could be required to complement more in-depth social contact approaches. • Lived experience leadership should be central from the research and design phase to delivery, evaluation, and review as well as at management and governance levels. • Activity needs to be tailored to each audience, context, and setting, • Ongoing evaluation should be the central aspect of any program, against a clear baseline. • Work must be sustained by building capacity and confidence and tools for employers and schools. Sustainability strategy • Support a lived experience movement by training and empowering champions to lead change. • Use impact data to support funding bids. • TTC hubs must embed anti-stigma focus within local policies (for example, local government and universities). • Embed changes to employer’s mental health policy and practice. • Embed mental health stigma within school management plans. • Provide templates for organizations to localize/contextualize. • Secure cross-sector and cross-party political support. Additional information Additional information: Available at https://changingmindsglobally.com/ Name and contract details for program managers: Program ended in 2021. Contact Sue Baker OBE, Changings Minds Globally https://changingmindsglobally.com (Time to Change and Time to Change Global Founding Director) or current stigma lead at Mind, George Hoare g.hoare@mind.org.uk. 49 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 2. Nōku te Ao o program (previously called Like Minds, Like Mine), New Zealand This is the world’s longest-running mental health stigma and discrimination program (1997– present) which contributed to significant improvements in public attitudes and reductions in discrimination at the national level. The focus of the new Nōku te Ao program is to work with and for the people most affected by discrimination including Māori and Pacific communities. It is a multilevel program based on kaupapa Māori principles, with media monitoring, research, training, and grants. Program overview Time span 1997–present Scale National and local The program is managed by the Health New Zealand | Te Whatu Ora Health Promotion Directorate. Program delivery is through a range of organizations Partners and including Māori public health organizations, the Mental Health Foundation, Te funders Whare Wānanga o Awanuiārangi (tertiary institute), a communications agency, and community-based organizations. Evaluation is undertaken by a research entity associated with Te Whare Wānanga o Awanuiārangi. Implementation • Target audience are those where people experience discrimination (health care settings, whānau/family and friends) as well as settings that influence Target culture change (for example, media). audiences • Benefit group is particularly Māori and Pacific peoples. Also, projects tackling equity issues for disabled and rainbow communities. • Social action grants - to resource projects led by individuals and community groups to tackle discrimination. • A community engagement arm to advocate the end of discrimination - to mobilize lived experience at the grassroots to challenge systemic discrimination through advocacy, policy engagement, storytelling, and media Project engagement. activities/ • Education and training for those working with mental health service users to methods understand how stigma and discrimination play a role in their services and indigenous methods for working differently. • Media grants, monitoring, training, and engagement. • Research projects and symposiums. • Program evaluation. Delivery team • The team comprises 3.4 FTE dedicated to the coordination of the program. The program has five NGO partners with varying degrees of staffing. Outcomes The program is evaluated on a yearly basis, with some additional case studies on Evaluation aspects of the program, such as grants. The current evaluation focused on the tools process for setting up the program, including utilizing indigenous approaches to contracting partners. Outcome evaluation will be reported in 2025. Evidence of • Discrimination: A study published in 2014 of 1,135 people who had recently effectiveness used mental health services found that over half reported an improvement in discrimination in the past five years and 48 percent thought that the ‘Like 50 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Minds, Like Mine’ program assisted in reducing discrimination (Thornicroft et al. 2013). • Wyllie and Lauder (2012). Cost- effectiveness/ The program’s evaluation methodology is kaupapa Māori which looks at Economic outcomes, relationships, approaches, values, and equity-focus. evaluation Lessons learned and recommendations • Develop strong and simple key messaging and call to action. • It is of vital importance that programs are led by people with lived experience. This means telling diverse stories of lived experience; experts, through experience, leading the program’s governance, communications, marketing, decision-making, and media relations; mentoring, enhancing skills, and resourcing experts by experience. • Cultural approaches should be prioritized when building a critical mass of supporters within a social movement to challenge discrimination. This means that cultural and indigenous knowledge informs language, methods of engagement, and conceptualization of the problem of discrimination; equity between clinical, cultural, and lived experience knowledge systems is required in decision-making and evaluation. • Resourcing needs to be devolved to the community groups to lead their own solutions. • Clinicians or non-cultural champions can take on advisory roles but cannot lead the overall movement. All human rights movements depend on those marginalized to be at the forefront. • The program requires significant and sustained resourcing to generate results. • Action is required across many levels from grassroots, systems change, media depictions, and research. Engagement with stakeholders across all sectors is needed to build profile and reach of messaging. Lived experience involvement This has been a key principle of the program across a wide range of communities but particularly Māori and Pacific communities. The success of the program is attributed to profile gained from well-known New Zealanders openly role-modelling as having lived experience. This became a talking point and broke down barriers to engaging with the messages as people identified themselves with these individuals who are leaders in their fields of music, sport, fashion, and culture. It is important to showcase a diverse range of lived experiences with different diagnoses, ethnicities, genders, and other demographics. Nōku te Ao has been borne out of its predecessor Like Minds, Like Mine as the latter had not equitably benefitted everyone in New Zealand. This meant that people from Māori and Pacific backgrounds as well as those with profound experience of mental health challenges (for example, received involuntary treatment) were less likely to benefit from the work. Nōku te Ao has moved to become grounded in New Zealand’s founding document, Te Tiriti o Waitangi, and led by people with lived experience from these communities. This works to change the lives of people most affected by discrimination, including Māori and Pacific communities. Additional information Links to programs websites: https://www.nokuteao.org.nz/ Links to key program reports/evaluations: https://kclpure.kcl.ac.uk/portal/en/publications/impact-of-the-like-minds-like-mine-anti-stigma- and-discrimination Name and contract details for program managers: Shaquille Graham - Shaquille.graham@tewhatuora.govt.nz 51 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 3. batyr program, Australia batyr is an Australian preventative mental health charity founded in 2011 and driven by young people, for young people. It was named after batyr (‘hero’) The Talking Elephant from Kazakhstan and gives a voice to the ‘elephant in the room’, the elephant being mental health. It delivers evidence-based programs in schools and universities that aim to reduce stigma around mental health and empower young people to reach out for support when needed. Activity is driven by young people sharing lived experience (the ‘Being Herd’ program trains young people to share their mental health experiences), contact-based interventions, mental health literacy training, and peer engagement. Program overview Time span 2011–present National with total reach of 408,188 young Australians “empowered to live a Scale mentally health life” since 2011 (excluding digital reach). Organizational expenditure report in 2020 (not all stigma-focused) AUD Funding 7,547,262. batyr is the lead agency, working with a wide range of partners (>400 schools Partners and 25 universities). It is funded by donations and corporate sponsors, government funds, and fees for services. batyr’s model was influenced by Dr. Patrick Corrigan and the TLC3 model (Targeted, Local, Credible, Continuous Contact), considered an efficient way to facilitate understanding and mental health literacy. It holds young people, specifically those with lived experience, at the center of their interventions. Model and Corrigan has done extensive research into contact-based anti-stigma evidence base interventions. Contact-based anti-stigma interventions involve planned interactions between people with a lived experience of mental ill-health and the public. A meta-analysis of 72 studies of contact interventions found that they had a positive effect on reducing public stigma in adolescents (Corrigan et al. 2012). Implementation Target Young people ages 14–30 and the communities that support them audiences ‘Being Herd’ program. Trains young people ages 18–30 to share their lived experience of mental ill-health in a safe and impactful way and has trained over 1,200 participants through the program, 424 of whom went on to become batyr storytellers, sharing their stories in high schools and universities. OurHerd app. The digital storytelling platform/app is for young people to share Project their lived experience stories of MH focusing on hope, resilience, and positivity. activities/ Everything posted on the app is moderated to ensure the content is safe for other methods users. Sentiment analysis, AI, and machine learning allows batyr to capture qualitative and quantitative data to draw insights from the lived experiences stories of OurHerd users, which is fed back to key decision-makers. • Educational workshops on mental health in schools, universities, and workplaces (in-person and online). 52 Reduction of Mental Health Related Stigma and Discrimination: Global Overview • Schools. Reaching over 400,000 students across 500 government and independent secondary schools). batyr currently runs programs with students in Years 9–12 and is developing Year 7 and Year 8 programs. o Teacher professional development. Interactive, collaborative workshops, where the role of teachers in the lives and MH of their students is discussed and they hear from a trained lived experience storyteller. o Universities. Young facilitators deliver educational content and with trained lived experience speakers. batyr also works with student volunteers to run activations and events on university campuses. o Work program. To engage entire workforces in mental health to provide a space for employees to safely explore and discuss the topic of mental health in the workplace. Campaigns. A multimedia channel campaign called ‘Going Beyond Polite Responses’ aims to “encourage young people to open up and talk about how they really feel” was launched in 2024 https://www.batyr.com.au/going-beyond- polite-responses Young people and people with lived experience are kept at the center of the Lived organization and all activity. Approximately 80 percent of the staff at batyr have experience had MH experiences, the board includes a young person, and a national advisory involvement group of young people feed directly into the board. Outcomes In 2020, batyr collaborated with The Centre for Social Impact to craft a theory of change and evaluation framework. This theory acts as a guide for measuring Evaluation impact and linking each outcome to specific measurement tools. Help-seeking tools behavioral intentions and attitudes related to mental health stigma and empowerment were measured before, immediately after a workshop/activity with students, and then at three-month follow-up in a large study in 2016 (see impact section below). • About 70 percent of young people who saw a batyr education program reported being more likely to reach out for support if they need it, compared to 22 percent of general Australians who access help when needed. • A Macquarie University study in 2017 conducted an RCT with 500 students which found that the school program reduced stigma and increased attitudes and intentions to seek professional mental health care, which was maintained at the three-month follow-up. • Regarding help-seeking, at baseline: 60 percent said they would seek help; immediately after the program: 72 percent said they would seek help; three Evidence of months follow-up: 68 percent. effectiveness • Changes in stigma, empowerment, and recovery attitudes demonstrated significant differences in responses from baseline to immediately after the batyr program, with improved attitudes for recovery and empowerment items) but not for stigma-related items. At three-month follow-up, the positive improvement in the empowerment item was significantly sustained. • In 2023, the University of Sydney found that help-seeking for personal, emotional, and mental health increased from 30 percent to 65 percent over six months. There was a link between the batyr@school program and lower levels of stigma. Sharing lived experiences was the most useful aspect of the program. 53 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Cost- Recent analysis by the University of Sydney provided a Social Return On effectiveness/ Investment (SROI) score which showed that for every US$1 spent on batyr Economic programs there was an SROI of US$13.40 for their work in regional communities. evaluation This was linked to the batyr@school program in disaster-affected communities (2023). Contextual factors Isolation is a key factor for people living in regional and rural parks of Australia. In response to this, the ‘Get Talkin’ Tour’ was implemented in 22 towns, reaching 3,259 people in regional communities (https://www.batyr.com.au/gettalkingtour/). The transition to a digital platform and the digital app ‘OurHerd’ (in response to the COVID-19 pandemic) also increased accessibility for regional, more-isolated populations, with online programs delivered to 11,000 people. Sustainability strategy • Diverse funding streams and longer-term funding partners • Use of technology. Additional information Key reports/evaluations: https://www.batyr.com.au/our-impact Program manager: Rob O’Leary, Lived Experience Program Manager ( rob@batyr.com.au). Tom Riley, Head of Impact (tom@batyr.com.au). Amy Brown, Head of Programs (amy@batyr.com.au). 54 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 4. Time to Change Global program, Africa and India Time to Change Global was a partnership project of UK mental health NGOs Mind and Rethink Mental Illness and the international disability and development organization CBM working with five country-level partners: Mental Health Society of Ghana , Grameena Abyudaya Seva Samsthe in India, Gede Foundation in Nigeria, Basic Needs Basic Rights Kenya, and Mental Health Uganda, and 111 people with lived experience who trained as champions across all five locations. Local champions shared their experiences at social contact events and as part of social marketing campaigns to improve public knowledge, attitudes, and intended behavior using the adapted core methodology of TTC. A Global Anti-Stigma Toolkit published in 2020 shared tools and experiences of partners and lived experience champions. An evaluation of the social marketing campaigns in Nairobi, Kenya and Accra, Ghana by KCL was published in 2021 (Potts and Henderson 2021). Program overview 2018–2020, program closed when funding ended but the Kenyan pilot ran until Time span 2023 Global and in five locations across Africa (Ghana, Nigeria, Kenya, and Uganda) Scale and India Funding £1.7 million (2 years) Mind, Rethink, CBMU UK, and five NGO partners in Africa and Southern India Partners with funding from the UK Government (FCDO) and Comic Relief. Core elements of the TTC program in England were adapted, having first Model and researched evidence of stigma projects and their impacts in low- and middle- evidence base income countries with research from Nigeria and India. Implementation • Local people with lived experience, with training to share mental health experiences Target audiences • General public—specific target audiences within local adult populations • Organizations and individuals interested in/already working on MH stigma (for the toolkit). • Research. Qualitative audience insight research with local populations via focus group discussions (FGDs) with adults in each community. Research with local champions. • Capacity-building training and support for project leads. Project • Training and support for lived experience champions in each location to activities/ safely and effectively share their MH experiences at social contact events methods and as part of the campaigns. • Social marketing campaigns. Co-production of a global anti-stigma toolkit ‘Conversations Change Lives’ based on the five pilot projects https://tinyurl.com/4tv9ttaf. • A global anti-stigma summit held in Kenya at the end of the program. 55 Reduction of Mental Health Related Stigma and Discrimination: Global Overview As with the England program, this was a core principle and co-production was a central approach to the work. Half of the Time to Change Global (TTCG) governance board were lived experience representatives with experience of Lived tackling mental health stigma (one person from Africa and one person from experience India) and local champions were instrumental in planning and delivering social involvement contact events, in shaping the social marketing campaigns, and then featuring in some of the creative and digital assets. Many of the teams globally and nationally had their own lived experiences. It was essential that each specific local context, culture, social norms, policy and Contextual legal frameworks relating to MH and services informed the development of factors campaigns and social contact events and the adaption of training modules for the project co-coordinators and lived experience champions. Delivery team UK program team of six with one coordinator in each of the five countries Outcomes • Mental health knowledge among target audiences in Ghana and Kenya assessed by MAKS with two additional questions added relating to beliefs Evaluation that mental illness is a curse and is genetically linked. tools • Public attitudes among target audiences (CAMI). • Public behavioral intentions among target audiences (RIBS). Evaluation of the social marketing campaigns in Ghana and Kenya. • MAKS - statistically significant improvement in Nairobi Evidence of • RIBS - statistically significant improvement in Ghana. The estimate for the effectiveness magnitude of this change is the same as TTC England for the general population between 2009 and 2019, a very promising result for a short-term public mental health campaign (Potts and Henderson 2021). Lessons learned and recommendations • Mental health stigma varies widely among individuals and communities worldwide, shaped by personal experiences, identity, and local contexts. Adapting any existing methods or tools to each specific context is vital with qualitative audience-insight research to understand the drivers of stigma in each location. • Lived experience involvement in anti-stigma work is vital for anti-stigma programs. • The pilot projects in Africa had a target audience of young people (ages 18–35) and with high levels of social media use. This allowed cost-effective campaigns with high levels of reach to be delivered via social/digital media and in some instances traditional media. Sustainability strategy Providing capacity-building training for local NGO teams and projects leads and for lived experience champions was aimed at sustaining the work beyond the funded period with champions continuing to campaign against stigma. The Basic Needs Basic Rights (BNBR) project in Kenya, with Mind and CBM, secured funding from Comic Relief to continue the ‘Speak Up’ stigma project until 2023. The toolkit has been widely used and referenced as an example of good practice for the global stigma toolkit being developed by the WHO and KCL. CBM UK is now the lead partner in the TTCG program and is actively seeking funding to re-start the pilots and extend and adapt the model. The same methods and some of the training modules have since been adapted with local partners and ministries by Sue Baker and her team in new regions and countries across Eastern Europe and the Caribbean. 56 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Additional information Links to programs websites: TTCGl website is no longer available, but information is available on other sites https://changingmindsglobally.com/. Links to key program reports/evaluations: Evaluation of anti-stigma social marketing campaigns in Ghana and Kenya: Time to Change Global (Potts and Henderson 2021). Name and contract details of program manager: Program ended in 2020. Contact Sue Baker OBE, Changings Minds Globally https://changingmindsglobally.com (Time to Change and Time to Change Global Founding Director). 57 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 5. Understanding Stigma and Strengthening Cognitive Behavioral Interpersonal Skills program, the Caribbean An online training program in the Caribbean to improve primary health care professionals’ confidence in the quality of mental health care they provide and reduce their levels of stigma. Research had shown the core barriers to changing practices in mental health care were the need to strengthen providers' capacity through knowledge and skills and address factors that impede motivation to change. Health care providers' stigmatization was also an important barrier to treatment in the Caribbean. Program overview Time span 2021–present Scale Across the WHO Caribbean region Partners PAHO and the Mental Health Commission of Canada Implementation Target Primary health care professionals in the Caribbean audiences The training program has two elements: • Online stigma-reduction component to help professionals recognize their Project own stigmatizing attitudes and behaviors, their impacts, how they present in activities/ primary care, using videos of personal stories. methods • The second element is the Cognitive Behavioral Interpersonal Skills that are virtually delivered and designed to increase providers' confidence to help clients recover. Outcomes • Health care professional’s confidence in the quality of the mental health care Evaluation they provided was improved. tools • Stigma among health care staff was reduced (Opening Minds’ Stigma Scale for Health Care Providers). • Significant improvements were observed on all measures of confidence and Evidence of comfort in the overall quality of mental health care they provided to clients. effectiveness • Stigma scale - statistically significant improvement in scores with a medium effect size on two of the OMS-HC subscales. Sustainability strategy To maximize sustainability and reproducibility standardized training and process documents were developed, and the Understanding Stigma component was translated into Spanish. Five tutors were trained and able to act as trainers in their country, with a booster session to aid learning retention. Additional information Key reports/evaluations: An initiative to improve mental health practice in primary care in Caribbean countries https://pubmed.ncbi.nlm.nih.gov/37363624/ Program managers: Mike Pietrus - mpietrus@openingminds.org, Claudina Cayetano - cayetanoc@paho.org. 58 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 6. NA ROVINU (On the Level) program, Czech Republic In 2013, the Minister of Health approved a strategy for a mental health care reform with the first phase (2023–2021) including a goal to reduce self-stigma and discrimination based on stigmatizing attitudes from health care staff, social workers, and others. The NA ROVINU program (roughly translated as ‘On the Level’) started in 2017. The major priorities of this program are to support people with lived experience in need of help and to continue mental health care reform. The program started with more focus on addressing mental health stigma and discrimination until 2022 and is now focused on prevention and MH literacy. Program overview Time span 2017–present Scale National with regional activity Funding 2017–2022 CZK 94.96 million (£3.3 million) The program is led by the National Institute of Mental Health, Czechia (NIMH CZ) Partners and funded by the Ministry of Social Affairs (sourced from European Structural Investment Funds). Someone from each target audience was involved in the development and design of the intervention. Pilots were conducted with focus groups to gain feedback on the program and structure. To evaluate progress, a pre-test was Model and conducted one week before the program, and a post-test one week after the evidence base program, and then again three months after. The implementers consulted members of the Global Anti-Stigma Alliance http://antistigma.global/. Recruiting people with lived experience was essential to developing the program. Implementation Specific target groups were chosen by people with lived experience as well as those eligible for funding (work with children and police officers was not eligible Target for funding). The chosen targets were people with lived experience, their audiences families, social workers, public administration workers, communities, and health care professionals (general practitioners, emergency services staff, and staff in general hospitals). • Training and support for people with lived experience—to share their Project experiences as part of delivery activities/ • Six toolkits designed for each target audience, and campaigns and methods communication were central. A central aspect of the program is the involvement of people with lived Lived experience in design, delivery, and evaluation with benefits for the program and experience people with lived experience involved in relation to self-esteem stigma. The involvement ability to speak openly of one’s experience is highly valued in this program. Adaptation mainly focused on molding the content of all provided modules to Contextual each of the six target groups based on situational analysis and communication factors with key experts and stakeholders and feedback from participants. During the COVID pandemic delivery was adapted to online methods. 59 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Outcomes Evaluation Public attitudes (nationally); intended behavior; self-stigma (people with lived tools experience) Quantitative data was collected through an online questionnaire with a set of scales completed before attendance, a week afterwards, and then three months later. Each target audience has a different set of scales adapted for them, focused Evidence of on attitudes and intended behaviors; for people with lived experience the focus is effectiveness self-stigma. At the national population level, • Public Attitudes: 2013–2019 - improvement with attribution to the campaign (Winkler et al. 2021). • Intended Behavior: 2013–2019 - no change (Winkler et al. 2021). Lessons learned and recommendations • It was essential to learn how best to work with people with lived experience and ensure they felt safe and comfortable to share their stories to audiences, and plan for situations when people had to step back from activity. • The focus on six predetermined groups was challenging because the program would at times prefer to focus on other populations, such as journalists. • The importance of evidence-based evaluation and the level of funds required had to be justified to stakeholders in the beginning. • Long-term monitoring and evaluation was also challenging, as the programs are short term and there is difficulty in following up with participants afterwards, particularly at the three- month follow-up. • Due to the COVID-19 pandemic, there existed challenges in getting individuals accustomed to online implementation. Sustainability strategy Future funding expected from the same funder (European Structural Investment Funds) with plans to generate revenues from the workplace activity. Additional information Website: https://narovinu.net/ Program contact: petr.winkler@nudz.cz Other key developments supporting anti-stigma programs The National Institute of Mental Health runs a perinatal project https://www.perinatal.cz/ with the goal of raising awareness of psychological difficulties in women in the perinatal period. 60 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 7. Working Minds program, Canada The Mental Health Commission of Canada was established in 2007, following a review of mental health (MH) and addiction services in the previous year, with a ten-year mandate to reconstruct MH systems and change attitudes and behaviors of Canadians in relation to MH. ‘Opening Minds’ was launched in 2009 to respond to the problem of stigma being a large barrier to help-seeking. The Working Mind (TWM) is a central part of the program’s work to reduce stigma and improve MH in the workplace. The Opening Minds program has a unique approach to developing, delivering, and evaluating activities to address MH stigma with all the target audiences (young people, health care workers, employers, and the media). Projects delivering similar interventions used similar evaluation tools for the effects to be compared across settings and decisions made about which to upscale on a national or international scale. Program overview Time span Opening Minds (2009–present) and The Working Mind (2014–present) Scale National and some international Opening Minds is self-sustaining and funded through its workplace training Funding programs. The Mental Health Commission of Canada funds and oversees the program. The Working Mind aspect of this work is now a separate entity that re-invests profits Partners from the income of its workplace delivery back into anti-stigma work and the Commission. Opening Minds chose to target the workplace due to moral, ethical, financial, and productivity reasons to reduce stigma and improve mental health. Workplace programs that address these barriers can reduce losses to workplace productivity and gain a positive return on investment outcomes. In terms of the employee, many individuals spend most of their days at work and may experience their mental health-related problems during their prime working Model and years (Szeto and Dobson 2010). Programs that reduce stigma and provide evidence base workplace mental health knowledge would likely increase help-seeking and may contribute to a more supportive workplace atmosphere. TWM was developed by clinicians and peers and based on scientific research and best practices. It was initially based on the Road to Mental Readiness (R2MR) program which was developed by the Department of National Defence to increase mental resiliency in soldiers with stressful and traumatic experiences. Implementation • Working Minds: Employers/the workforce including adaptations for health Target care providers, first responders, lawyers, professional and amateur audiences sportspersons, and so on. • Opening Minds: Young people, health care professionals, the media. 61 Reduction of Mental Health Related Stigma and Discrimination: Global Overview • Opening Minds: Contact-based education • Mental Health First Aid (MHFA) • The Inquiring Mind (TIM) is designed to meet the needs of post-secondary and high school students and help them cope with the unique challenges Project and stressors found in an educational setting. activities/ • The Working Mind (TWM) training aims to reduce stigma and promote methods mental health in the workplace, creating a more resilient and supportive culture among employees and leaders. It is structured into four interactive modules with videos, case studies, and practical exercises. These cover ‘Mental Health and Stigma’, ‘The Mental Health Continuum’, ‘Stress and Resilience’, and a fourth module ‘Supporting Your Team’ only for managers. The courses are offered in-person or virtually. Lived • Opening Minds includes the points of view of people with lived experience of experience mental ill health. The ‘Hallway Group’ consists of Canadians with lived involvement experience as advisors. Videos used in training feature the recovery stories of people with lived experience. • TWM also operates in Australia and the US. They prioritize cultural uptake, Contextual which is enabled by organizational readiness, strong leadership support, factors ensuring good group dynamics, credibility of trainers, and implementing the program as one piece of a larger program (Dobson, Szeto, and Knaak 2019). Outcomes Evaluation (The Working Mind): Reductions in stigma; increases in resilience; overall mental tools health literacy; overall mental wellness. • The Working Mind was associated with moderate reductions in stigma and increased self-reported resilience and coping abilities (Dobson, Szeto, and Knaak 2019). The program also decreased mental health stigma and increased self-reported resilience and coping skills which were maintained at Evidence of the three-month follow-up (Dobson et al. 2021). effectiveness • An evaluation of The Road to Mental Readiness (for first responders) indicated that the program increased participants’ perceptions of resiliency and decreased stigmatizing attitudes, which were mostly maintained at the three-month follow-up. The program increased mental health support for first responders (Szeto, Dobson, and Knaak 2019). Lessons learned and recommendations • Specialized programs are more effective than generalized programs with information that is more tailored to the local context and such programs benefit from learning from the local community. • Evidence-based information is crucial, using both quantitative and qualitative information. • It is beneficial to start the anti-stigma process as early as possible, as children as young as two or three years old are already developing perception and young people are also more open and supportive to people with mental health conditions. • Lowering stigma requires generational change, namely a long-term commitment. • Challenges of this program include the absence of a large, publicly visible anti-stigma effort as would have been the case if a large media campaign had been used. • Working Minds had the best engagement when working with someone at managerial level, who was more likely to understand the importance and effects of mental health conditions in the workplace. • Focus on sustainability, as many anti-stigma programs unfortunately end because of lack of funding. 62 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Sustainability strategy • Income generation model funds the ‘Opening Minds’ program and returns a profit to fund other projects • Sustainability of Impact: Booster sessions were an important component of sustainability as pre and post studies found that after training, people maintained the effects for three months, but at six months they saw a drop in the use and knowledge of the training. Additional information Website: https://openingminds.org/training/twm/ Program contacts: Mike Pietrus (mpietrus@openingminds.org). 63 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 8. More Than a Label program, Hong Kong The pilot anti-stigma program started in 2019 with initial funding from a Hong Kong Foundation, followed by the program launch in 2021. The Hong Kong Government funds its own campaign which is not linked. Program overview Time span 2019-present with funding secured until 2025 Scale National population-wide since 2021 Funding Current average budget HKD 1.5 million/approximately £150,000 Partners Mind HK. Funder is MINDSET (Jardine Matheson Group Charity) Model and All three elements are ‘evidence-based best practice’. Initial methods, models, evidence base/ and evaluation framework guided by TTC and adapted and piloted to local foundations content. Implementation Target • Public - Hong Kong residents (adults mostly working age) and health care audiences providers • Ambassadors—122 local people with lived experience of mental health problems provided with bilingual training and ongoing support to safely and effectively share their mental health experiences in public (social contact events, online, in campaigns). • Community events (using social contact)—over 100 events in public Project settings, workplaces, schools. activities/ • Social marketing campaign—large-scale annual campaign bursts with social methods and traditional media. • Owned social media channels—4,000 followers on Instagram and 31,191 views of campaign videos. • Stakeholder engagement—extending reach to a wide range of communities. Delivery team • 4 people (2 full time and 2 part time) • Strategic Input: Advise on strategy every cycle and all campaign planning and involved in all aspects of program development, will also be on all Lived steering groups and the Program Advisory Board. experience • Activity-level Input: Co-train new ambassadors, develop and deliver some involvement new ambassador training content, develop and plan their own social contact events, feature in campaigns, and share experiences at social contact events and on owned social media channels. • Any illness attracts a lot of shame. Stigma is related to ‘not being perfect’ including mental health and cancer both of which are seen as a weakness or Contextual reflection of your DNA. This is more prevalent in older generations, but factors some for young people this can be ‘deeply ingrained’. • The attitude survey shows that almost half the population think mental health issues are a result of a lack of will power, and there is also a pressure to succeed—both result in a ‘saving face’ culture. 64 Reduction of Mental Health Related Stigma and Discrimination: Global Overview • Ethnically Chinese ambassadors sometimes prefer to share their mental health stories in English as they feel that some mental health terminology in Chinese is stigmatizing. Outcomes • A sample of public who viewed campaign videos showed a significant positive improvement in attitudes and intended behavior but not MAKS as a total score but the stigma subscale did improve. • A survey of general and mental health nurses using the OMS-HC-15 scale showing positive improvement in mental health stigma scores after Evidence of ambassadors had shared their stories. effectiveness • Ambassadors. Three themes emerged; “the impact goes both ways” with improved healing and self-discovery, sharing lived experience is “emotionally challenging,” and the importance of the supportive community of peers who are ambassadors and the support from Mind HK team. • The 2021 survey of 1,010 adults to assess attitudes toward mental health issues in Hong Kong conducted by Social Policy Research Limited. • Mental Health Knowledge Scale (MAKS), Community Attitudes on Mental Public attitudes Illness scale (CAMI) and Reported and Intended Behaviour Scale (RIBS) of adults validated tool in Chinese and English used on a smaller sample size before and after seeing campaign videos featuring ambassadors. • Health care providers: OMS-HC tool used in a pre and post survey following ambassador-sharing session. Lessons learned and recommendations • While the experience of being an ambassador and learning to shared mental health experiences showed positive results for the ambassadors, it was also a ‘difficult’ thing to do. People applying to become trained ambassadors will need be screened before they trained and offered ongoing support. • Male engagement has been difficult from a cultural perspective but is improving and increasing reach with men through partnership and male-focused events. Additional information Website: https://www.mind.org.hk/press-releases/mind-hk-and-mindset-hong-kong-launch- honestlyspeaking-a-bold-new-campaign-to-combat-stigma-against-mental-health-conditions/ Mind HK: https://www.mind.org.hk/mtal/ Program contacts: Odile Thiang - odile.thiang@mind.org.hk, Carol Liang - carol.liang@mind.org.uk Other key developments supporting anti-stigma programs • The Hong Kong Government’s anti-stigma campaign ‘Shall We Talk’ ran for a few years. The campaign used traditional and social media channels with a high-profile celebrity singer. • The City Mental Health Alliance HK is a Hong Kong division https://www.cmhahk.org/ with membership by large corporates focused on mental health and well-being at work. It is part of a larger global network of employers called the Mind Forward Alliance https://mindforwardalliance.uk/. 65 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 9. Mental Health Supporter Training program, Japan The Mental Health Supporter Training Program is a Japanese adaption of the MHFA program led by the National Institute of Mental Health between 2020 and 2023. Program overview Time span Pilot 2020–2023; National upscale 2024–2033 National upscale across 1,700 municipalities with a target of 1 million people Scale trained by 2033 The Ministry of Health funded the development and early rollout period when 7,000 adults were trained (average age 44). From 2024, a private contractor is delivering a national program of training in large-scale and middle-scale cities Partners with a target of training 1 million people as ‘Cocoro Supporters’ by 2033. In recent years, there was a similar program of training to enable people to be more supportive of people with dementia that saw 10 million people trained. Model and The program was partly based on the original MHFA model. evidence base Implementation Target Adult residents in Japan (there were no exclusion criteria) audiences A two-hour online training to help participants better understand mental illness and learn about support techniques for people with mental health difficulties close to them. The content of the training focused on goal of the program Project (5 min); what is a mental health supporter (10 min); learning about mental activities/ illness, learning about recovery from mental illness (8 min); how to support the methods mental health of people close to you, workshops, and wrap-up (45 min). There are two additional modules that can be chosen: Self-care through coping with stress and learning about mental illness. Outcomes The following outcomes and tools were used in the evaluation of the initial program. The research team recommended the inclusion of the stigma-related RIBS scale to measure intended and reported behavior. • Primary Outcome: The Japanese version of the Reported and Intended Evaluation Behaviour Scale (RIBS-J) with both the intended and reported subscales. tools • Secondary Outcomes: Japanese Version of the Mental Health Literacy Scale (MHLS), psychological distress using the Kessler Psychological Distress Scale 6 (K6) (based on the premise that listening to people around them may reduce interpersonal conflict and improve their own mental health), and mental health knowledge using questions developed by the authors. The published study aimed to examine the effects of the Mental Health Supporter Training Program on mental health-related stigma, mental health literacy, and knowledge of mental health among Japanese people trained between October 2022 and February 2023 across 18 municipalities, and to investigate the feasibility Evidence of of the program. Pre and post assessments were undertaken at baseline (T1), effectiveness immediately after the training (T2), and approximately six months later (T3) with the following results: • RIBS-J. Despite the mean intended behavior score increasing at statistically significant levels between T1 and T2, it returned to the baseline level at T3 66 Reduction of Mental Health Related Stigma and Discrimination: Global Overview showing no longer-term effect. The mean reported behavior score increased and remained the same at T3 but the effect size was small. • The scores for Mental Health Literacy (knowledge and attitude) increased from T1 to T2 at significant levels for both knowledge and attitudes and remained the same at T3. • Mental health knowledge score increased at significant levels from T1 to T2 and the same at T3. • The psychological distress score showed a small but significant change at T3. The results show the impacts of the program on improving mental health literacy, knowledge of mental health, and reducing levels of psychological distress but not longer-term impacts on intended and reported behavior of trained participants. Lessons learned and recommendations • Two possible causes were discussed for the lack of sustained effectiveness: the contents of the program (with only a brief introduction to the experience of people with mental illness) and the lack of follow-up. • Authors also discussed whether the T3 follow-up at six months was too soon for respondents to have had social contact with people with mental health problems over that period (for the reported subscale), and that changing negative behavior with only one intervention could be difficult and that other follow-up interventions might be necessary. Sustainability strategy The upscaling strategy, which could support sustainability efforts, is that local municipalities fund the delivery of the training (with the ending of national government funding); however, there are concerns that only those areas with more resources will be able to provide funding. Additional information Links to programs website. Coco-sapo https://cocoroaction.jp/en/ Program evaluation. “Effects of the Mental Health Supporter Training Program on mental health- related public stigma among Japanese people.” Psychiatry and Clinical Neurosciences Reports, March 2024. https://onlinelibrary.wiley.com/doi/10.1002/pcn5.176. (*) June 2024 update. Findings in a new paper (the purpose of which was to modify the program evaluated in the previous study and verify its effectiveness for participants in the FY2023 program), “suggested that the combination of educational and contact-based interventions might reduce public stigma toward people with mental health problems immediately post intervention, an effect that persists 3 months later.” https://onlinelibrary.wiley.com/doi/full/10.1002/pcn5.219 Name and contact details for previous program manager. Naoaki Kuroda - nkuroda@ncnp.go.jp. Daisuke Nishi - d-nishi@m.u-tokyo.ac.jp (led until 2023) Other key developments supporting anti-stigma programs: • Renaming of schizophrenia in 2002, which aimed to reduce stigma (following media analysis) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1472254/ • Ministry of Education has included an item on prevention and recovery from mental disorders in the high school curriculum since 2022. 67 Reduction of Mental Health Related Stigma and Discrimination: Global Overview 10. ‘Beyond the Label’ program, Singapore The national Beyond the Label (BTL) movement was initiated and funded by the National Council of Social Service (NCSS) and is now a collective impact initiative co-led with TOUCH Community Services. The ‘BTL Collective’ is a national movement with many public, voluntary, and private sector agencies and stakeholders involved. The movement seeks to build community expertise to convene people, private and public agencies to work toward a common goal of addressing stigma and promoting social inclusion for people with mental health conditions (PMHCs). Program overview Time span Launched in 2018 until 2021 with a second phase from 2022 to 2028 Scale National scale from the outset in 2018 SGD 2 million /£1.2 million GBP per year. Funds from the government, corporate Funding sponsors, trusts, donations The NCSS set up BTL in response to data from two surveys showing that the most common drivers were low mental health literacy and stigma. • About 7 in 10 people with mental health conditions encounter challenges living with dignity due to negative attitudes and actions from others Quality of Life Study 2016 (NCSS). Partners • The prevalence of public misconceptions about people with mental health conditions including fear, a lack of understanding, and the influence of the media contribute to “deep-seated stigma prevalent in society” in another NCSS study of Public Attitudes towards Persons with Mental Health Conditions in 2017. This also found that 75 percent would not seek help for a mental health problem for more than a year. Implementation Target • Families and caregivers; children and young people; communities; audiences employers • THE BTL Collective—34 agencies from the public, private, and people sectors adding leverage and reach. • Social marketing campaign. Let’s Get Talking—the aim of the latest campaign is to encourage persons with mental health conditions to share their stories of strength and resilience, and to seek help early. • Community engagement—events, roadshows, talks/workshops, and a grant for the BTL workgroups to implement their initiatives • Ambassadors with lived experience who share their stories with the public Project to inspire others facing similar struggles to speak up and seek help. activities/ • Beyond the Label chatbot ‘Belle’—for people struggling with stress or methods anxiety or their families/friends which is now also available via WhatsApp and online. Belle will be consolidated with Mindline.sg, a digital first-stop touchpoint for mental health resources and support from January 1, 2025. Current users of Belle will be directed to Mindline.sg, where they can access a self-assessment tool that allow users to be directed to relevant mental health resources and services. • Workplace—Employer Pledge and Resources, panel dialogue/workshops, targeted campaign. • Higher education—Roadshows in institutes of higher learning. 68 Reduction of Mental Health Related Stigma and Discrimination: Global Overview • Schools. Psychoeducation talks, the Beyond the Label Plug and Play Kit is a toolkit offering a wide range of activities that provides young people resources and tips for launching their own anti-stigma initiatives. Despite some positive shifts in attitudes after the introduction of BTL, the issue of stigma is prevalent. The 2021 NCSS Study on Attitudes towards Persons with Mental Health Conditions has shown that four in five people felt that persons with mental health conditions were stigmatized, four in ten0 were willing to live with persons with mental health conditions, and one in four believed that lack of self- discipline was the cause of mental health conditions. If not addressed, these negative attitudes and misconceptions can be expected to perpetuate a culture of stigma that deters persons with mental health conditions from seeking help or being included. Contextual Since COVID-19, mental health is a national priority. An Inter-agency Taskforce on factors Mental Health and Well-being was established by the Government in 2021 to oversee national efforts to promote mental health and well-being beyond the COVID-19 pandemic. The taskforce has since launched Singapore’s National Mental Health and Well-being Strategy in 2023, which covers the following focus areas: (a) expanding capacity of mental health services, (b) enhancing capabilities of service providers for early identification and intervention, (c) promoting mental health and well-being, and (d) improving workplace mental health and well-being. In a parliamentary motion in February 2024, the then Deputy Prime Minister stated that the government is making mental health and well-being a key priority in the national agenda. Outcomes Public attitudes (including knowledge, attitudes, and behavior): A 2021 NCSS Evaluation Study on Attitudes towards Persons with Mental Health Conditions of 2,000 tools Singaporean residents using the Community Attitudes toward the Mentally Ill (CAMI-12) Scale, Reported and Intended Behaviour Scale (RIBS), and Mental Health Knowledge Schedule (MAKS). Public survey to assess improvements in public attitudes and behavior toward persons with mental health conditions; increase in public awareness and Evidence of understanding of mental health conditions and resources. effectiveness • About 25 percent higher on the knowledge scale; 10 percent higher on the behavior scale; 15 percent higher on the attitude scale by the end of 2028, with 2022 data as baseline. Lessons learned and recommendations • Youth play an important part in this movement. Creating a non-labelling space for young people was vital for mental health promotion and prevention approaches. Young people who need help were finding it hard to locate this, so in 2019 the online chatbot ‘Belle’ was developed and is now an online ‘escape room’ developed during COVID. Young people are also more openly discussing mental health particularly on social media. • Understanding that reducing stigma and promoting social inclusion requires moving beyond raising awareness alone, the next phase of BTL will take on a more targeted approach with intentional community outreach and engagement efforts in schools, workplaces, families, and communities. 69 Reduction of Mental Health Related Stigma and Discrimination: Global Overview Sustainability strategy NCSS has secured funding for the BTL movement until 2028. Additional information Program website: https://www.ncss.gov.sg/our-initiatives/beyond-the-label Program manager: TOUCH Community Services (btl_admin@touch.org.sg) and NCSS Service Delivery (btl_admin@touch.org.sg) Other anti-stigma projects/programs: City Mental Health Alliance Singapore https://mindforwardalliance.uk/CMHA-Singapore/1284-/CMHA-Singapore-Linklaters-Heineken 70