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Mass media interventions for reducing mental health-related stigma

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Mass media interventions for reducing mental health-related stigma
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      F   o   r     P   r   e   v    i   e   w    O   n    l   y Mass media interventions for reducing mental health-relatedstigma (Review) Clement S, Lassman F, Barley E, Evans-Lacko S, Williams P, Yamaguchi S, Slade M, Rüsch N,Thornicroft G Thisisareprintof aCochrane review, preparedandmaintained byThe Cochrane Collaboration andpublishedin  TheCochrane Library  2013, Issue 6http://www.thecochranelibrary.com Mass media interventions for reducing mental health-related stigma (Review)Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.      F   o   r     P   r   e   v    i   e   w    O   n    l   y T A B L E O F C O N T E N T S 1HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4SUMMARY OF FINDINGS FOR THE MAIN COMPARISON . . . . . . . . . . . . . . . . . . .6BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Figure 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Figure 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Figure 4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Figure 5. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Figure 6. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Figure 7. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Figure 8. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Figure 9. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Figure 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Figure 11. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28Figure 12. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2931DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36 ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Analysis 1.1. Comparison 1 Mass media vs. control: main comparison, Outcome 1 Discrimination (Immediate). . . 114 Analysis 1.2. Comparison 1 Mass media vs. control: main comparison, Outcome 2 Discrimination. . . . . . . 114 Analysis 1.3. Comparison 1 Mass media vs. control: main comparison, Outcome 3 Prejudice. . . . . . . . . 115 Analysis 1.4. Comparison 1 Mass media vs. control: main comparison, Outcome 4 Prejudice. . . . . . . . . 117 Analysis 2.1. Comparison 2 Mass media vs. control by income of country, Outcome 1 Prejudice (at earliest follow-up timepoint). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 Analysis 3.1. Comparison 3 Mass media vs. control by number of mass media components, Outcome 1 Prejudice (at earliestfollow-up time point). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119 Analysis 4.1. Comparison 4 Mass media vs. control by whether combined with non-mass media, Outcome 1 Prejudice (atearliest follow-up time point). . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120 Analysis 5.1. Comparison 5 Mass media vs. control by presence of narratives, Outcome 1 Prejudice (at earliest follow-uptime point). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121 Analysis 6.1. Comparison 6 Mass media vs. control by celebrity narratives, Outcome 1 Prejudice (at earliest follow-up timepoint). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122 Analysis 7.1. Comparison 7 Mass media vs. control by fictional narratives, Outcome 1 Prejudice. . . . . . . . 123 Analysis 8.1. Comparison 8 Mass media vs. control by type of message, Outcome 1 Prejudice (at earliest follow-up timepoint). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124 Analysis 9.1. Comparison 9 Mass media vs. control by type of media, Outcome 1 Prejudice (at earliest follow-up timepoint)). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125126 ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132 APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .150CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .151DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . iMass media interventions for reducing mental health-related stigma (Review)Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.      F   o   r     P   r   e   v    i   e   w    O   n    l   y [Intervention Review] Mass media interventions for reducing mental health-relatedstigma Sarah Clement 1 , Francesca Lassman 1 , Elizabeth Barley  2 , Sara Evans-Lacko 1 , Paul Williams 1 , Sosei Yamaguchi 3 , Mike Slade 1 , NicolasRüsch 4 , Graham Thornicroft 11 HealthServiceandPopulation ResearchDepartment,King’sCollegeLondon, Institute ofPsychiatry,London, UK. 2 FlorenceNightin-gale School of Nursing and Midwifery, King’s College London, London, UK.  3 Department of Psychiatric Rehabilitation, NationalInstitute of Mental Health, National Center of Neurology and Psychiatry (NCNP), Tokyo, Japan.  4 Department of Psychiatry II, UlmUniversity, Ulm, Germany Contact address: Sarah Clement, Health Service and Population Research Department, King’s College London, Institute of Psychiatry,Box PO29, David Goldberg Centre, De Crespigny Park, London, SE5 8AF, UK. sarah.clement@kcl.ac.uk . Editorial group:  Cochrane Consumers and Communication Group. Publication status and date:  New, published in Issue 6, 2013. Review content assessed as up-to-date:  31 July 2012. Citation:  Clement S, Lassman F, Barley E, Evans-Lacko S, Williams P, Yamaguchi S, Slade M, Rüsch N, Thornicroft G. Mass media interventions for reducing mental health-related stigma.  Cochrane Database of Systematic Reviews   2013, Issue 6. Art. No.: CD009453.DOI: 10.1002/14651858.CD009453.Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. A B S T R A C T Background Mental health-related stigma is widespread and has major adverse effects on the lives of people with mental health problems. Itstwo major components are discrimination (being treated unfairly) and prejudice (stigmatising attitudes). Anti-stigma initiatives ofteninclude mass media interventions, and such interventions can be expensive. It is important to know if mass media interventions areeffective. Objectives Toassesstheeffectsofmassmediainterventionsonreducingstigma(discrimination andprejudice)relatedtomentalillhealthcomparedto inactive controls, and to make comparisons of effectiveness based on the nature of the intervention (e.g. number of mass media components), the content of the intervention (e.g. type of primary message), and the type of media (e.g. print, internet). Search methods  We searched eleven databases: the Cochrane Central Register of Controlled Trials (CENTRAL,  The Cochrane Library,  Issue 7, 2011);MEDLINE (OvidSP),1966 to 15 August 2011; EMBASE (OvidSP),1947 to 15 August 2011; PsycINFO (OvidSP), 1806 to 15 August 2011; CINAHL (EBSCOhost) 1981 to 16 August 2011; ERIC (CSA), 1966 to 16 August 2011; Social Science Citation Index (ISI), 1956 to 16 August 2011; OpenSIGLE (http://www.opengrey.eu/), 1980 to 18 August 2012; Worldcat Dissertations and Theses(OCLC), 1978 to 18 August 2011; metaRegister of Controlled Trials (http://www.controlled-trials.com/mrct/mrct_about.asp), 1973to 18 August 2011; and Ichushi (OCLC), 1903 to 11 November 2011. We checked references from articles and reviews, and citationsfrom included studies. We also searched conference abstracts and websites, and contacted researchers. Selection criteria  Randomised controlled trials (RCTs), cluster RCTs or interrupted time series studies of mass media interventions compared to inactivecontrols in members of the general public or any of its constituent groups (excluding studies in which all participants were people withmental health problems), with mental health as a subject of the intervention and discrimination or prejudice outcome measures. 1Mass media interventions for reducing mental health-related stigma (Review)Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.      F   o   r     P   r   e   v    i   e   w    O   n    l   y Data collection and analysis Two authors independently extracted data and assessed the risk of bias of included studies. We contacted study authors for missing information. Information about adverse effectswas collectedfrom study reports. Primary outcomes were discrimination and prejudice,and secondary outcomes were knowledge, cost, reach, recall, and awareness of interventions, duration/sustainability of media effects,audience reactions to media content, and unforeseen adverse effects. We calculated standardised mean differences and odds ratios. Weconducted a primarily narrative synthesis due to the heterogeneity of included studies. Subgroup analyses were undertaken to examinethe effects of the nature, content and type of mass media intervention. Main results  We included 22 studies involving 4490 participants. All were randomised trials (3 were cluster RCTs), and 19 of the 22 studies hadanalysable outcome data. Seventeen of the studies had student populations. Most of the studies were at unclear or high risk of bias forall forms of bias except detection bias.Findings from the five trials with discrimination outcomes (n = 1196) were consistent with a reduction, increase or no effect. Themedian standardised mean difference (SMD) for the three trials (n = 394) with continuous outcomes was -0.25 with SMDs ranging from-0.85 (95% CI -1.39 to-0.31) to -0.17 (95% CI -0.53 to0.20). Oddsratios (OR) for thetwo studies (n =802) with dichotomousdiscrimination outcomes were 1.30 (95% confidence interval (CI) 0.53 to 3.19) and 1.19 (95% CI 0.85 to 1.65).The 19 trials (n = 3176) with prejudice outcomes had median SMDs of -0.38, -0.38 and -0.49 at the three follow-up time periods(immediate, 1 week to 2 months, 6 to 9 months). SMDs for prejudice outcomes in each study ranged from -2.94 (95% CI -3.52 to -2.37) to 2.40 (95% CI 0.62 to 4.18). The median SMDs indicate that mass media interventions may have a small-to-medium effectin decreasing prejudice, and are equivalent to reducing the level of prejudice from that associated with schizophrenia to that associatedwith major depression.The studies were very heterogeneous, statistically, in their populations, interventions and outcomes. and only two meta-analyses withintwo subgroups were warranted. Data on secondary outcomes were sparse. Cost data were provided on request for 3 studies (n = 416),were highly variable, and did not address cost-effectiveness. Two studies (n = 455) contained statements about adverse effects andneither reported finding any.  Authors’ conclusions Mass media interventions may reduce prejudice, but there is insufficient evidence to determine their effects on discrimination. Very little is known about costs, adverse effectsor other outcomes. Our review found few or no studies in middle-and low-income countriesor with children and adolescents, employers or health professionals as the target group. The findings are limited by the quality of theevidence, which was low for the primary outcomes for discrimination and prejudice, low for adverse effects and very low for costs.More research is required to establish the effects of mass media interventions on discrimination, to better understand which types of mass media intervention work best, to provide evidence about cost-effectiveness, and to fill evidence gaps about types of mass media not covered in this review. Such research should use robust methods, report data more consistently with reporting guidelines and beless reliant on student populations. P L A I N L A N G U A G E S U M M A R Y Mass media interventions for reducing stigma towards people with mental health problems People define stigma in various ways. In this review we focus on two key aspects of stigma: discrimination (treating people unfairly because of the group theybelong to) and prejudice (negative attitudes and emotions towards certain groups). Peoplewith mental healthproblems oftenexperience stigma. It can have awful effectson their lives. Mass media are media that are intended to communicate withlarge numbers of people without using face-to-face contact. Examples include newspapers, billboards, pamphlets, DVDs, television,radio, cinema, andtheInternet.Anti-stigma campaigns ofteninclude massmediainterventions, andcanbe expensive,soitisimportantto find out if the use of mass media interventions can reduce stigma. We reviewed studies comparing people who saw or heard a mass media intervention about mental health problems with people whohad not seen or heard any intervention, or who had seen an intervention which contained nothing about mental ill health or stigma. We aimed to find out whateffectsmass media interventions may have on reducing stigma towards peoplewith mental healthproblems. 2Mass media interventions for reducing mental health-related stigma (Review)Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.      F   o   r     P   r   e   v    i   e   w    O   n    l   y  We found 22 studies involving 4490 people. Five of these studies had data about discrimination and 19 had data about prejudice. Wefoundthatmassmediainterventions mayreduce,increase, orhavenoeffectondiscrimination. Wefoundthatmassmediainterventionsmay reduce prejudice. The amount of reduction can be considered as small-to-medium and is similar to reducing the level of prejudicefrom that associated with schizophrenia to that associated with major depression. The quality of the evidence about discrimination andprejudice was low, so we cannot be very certain about these findings. Only three studies gave any information about financial costs andtwo about adverse affects, and there were limitations in how they assessed these, so we cannot draw conclusions about these aspects. 3Mass media interventions for reducing mental health-related stigma (Review)Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
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