Andrew Thorp, Program Leader, Stigma & Discrimination, Beyond Blue, Melbourne:
Beyond Blue does a lot of research into anxiety, depression, and suicide. And over the years, we continue to find that men in their middle years are less likely to seek support and have the highest rates of stigma.
Stigma means a whole range of things. At a structural level there's discrimination that can happen if the policies and procedures of an environment like a school or a workplace are not sufficient. There's social stigma, where there's prejudice in between groups of people. There's self-stigma, which is the shame and the blame that often internalises somebody experiencing a mental health condition.
The STRIDE Initiative, which stands for Stigma Reduction Interventions (Digital Environments) commenced in 2013. It's a research [00:01:00] program that was funded thanks to the Movember Foundation to really identify whether digital platforms, like websites and apps, can be used to reduce stigma amongst men in their middle years.
Beyond Blue went out and looked for community-academic partnerships and what we really wanted was academics, who often have that really strong evidence base, to partner with community organisations on the ground because we know that involving the community, the target audience, [00:01:30] is really important in effective stigma reduction.
Dr Alison Kennedy, Research Fellow, National Centre for Farmer Health, Hamilton:
Well, The Ripple Effect is a website which is designed to reduce the stigma associated with an experience of suicide. It's particularly focused on targeting males from the farming community who are aged between 30 and 64 years.
Within rural communities, I think we face a [00:02:00] number of hurdles when we're both talking about something like suicide and also making that in a digital format. We know this is an age where people are at high risk of suicide.
I do remember having a conversation with one gentleman who'd lost his younger brother to suicide a couple of decades earlier. He felt that if he put up his hand and said that he was struggling a bit that people would no longer trust him and he may very well lose his farming business because of that. He was a contractor.
Using a digital intervention had its challenges but also its advantages. It wasn't something that they necessarily had to sit for a certain amount of time in a certain place. They may be in the tractor for half an hour and have a moment when the tractor's set on GPS, to actually just log in and do a little bit more of their pathway through the website.
I guess one of the really meaningful results that we've found, a greater willingness to talk about emotional issues in an environment, I guess, where they weren't being judged, and a willingness to speak out. We found over half of the people that participated in the workshop, this was actually the first time that they had spoken about their experience publicly, which was a great way to begin that reduction of stigma.
I think if we were doing the project again and thinking about how we might do things differently, I think we would possibly structure our timelines a little better, giving ourselves more time for that tricky recruitment phase and that ongoing community engagement phase.
The Ripple Effect has had a profound effect, really, on the community and not only those who've participated, but also on those who have heard about the project and become interested in it. It's really started some fantastic conversations and some really powerful messaging.
Caleb Hawk, Communications Coordinator, Victorian AIDS Council, Melbourne:
The Out of the Blue project is… the concept is a single wire frame that we use to create two different websites.
pete.org.au is aimed at men living with HIV or experience anxiety and or depression and then dale.org.au is aimed at same-sex attracted men living in a heterosexual relationship or lifestyle. They're commonly called gay and married men.
We're dealing with a compound complex stigma since it's not only the stigma associated with mental health, but this other form of stigma that's either same-sex attraction or living with HIV that's woven in there together. The idea behind the site is that we're using a dual approach with an education approach and a contact approach through different elements on the site. For education approach, we've got a series of articles which are either short-form articles about basically establishing a common understanding of anxiety, depression, treatment, signs, symptoms, and then you've also got personal stories, which are longer form articles from the lived experiences of men from either of those two populations. For the connect approach or the contact approach, we developed a bespoke solution online, which is the live chat sessions, which are peer moderated sessions around a specific topic. Guys could come onto the site and not present... not have to walk through their threshold of a physical space that they might feel like there's some perceived stigma already attached to.
The other big advantage is that men can be from anywhere across the country. That's a big thing that we have to face a lot through VAC and ACON and a couple of the other services out there that have previously engaged these men ... Is that oftentimes they have to be in the same geographic proximity. In the online space, they can be in the middle of Broken Hill or they can be right in Melbourne’s CBD and it doesn't matter. That's really great for both of these populations of men because to build up that critical mass around peer support and peer connection, you do need to have everybody in the same place, at the same time. In face-to-face services you have to physically be there, but in the digital space, you basically just have to have a smart phone and a WiFi connection and you're on your way.
With the Out of the Blue Project with Pete and Dale, we had very different results. We saw a level of digital engagement on both sites, but I guess the biggest learning from all of that is the communities take a long time to build and that's true in face-to-face as well as online. Through our baseline surveys, we did get enough data from the Dale survey to get a bit of information about a population that we really didn't have any quantitative research on before. We actually have the largest ... what we believe to be the largest quantitative study around the mental health of these men, and those experiences of stigma.
Mental health stigma doesn't sit in isolation. Being able to start that conversation with these communities is a great step forward, but it's only really a starting point. As these online communities build, we can grow from that to touch on a lot of other related issues that affect their overall health and wellbeing outcomes.
Dr Angela Nickerson, Director, Refugee Trauma and Recovery Program, University of New South Wales, Sydney:
The Tell Your Story Project is really an online intervention designed to reduce mental health stigma and increase [00:07:00] help seeking amongst refugee men. It's estimated that around one in three refugees and asylum seekers has a diagnosis of Post-Traumatic Stress Disorder, or PTSD, but despite this we know that very few refugees and asylum seekers seek help for these psychological difficulties. One of the key barriers to this is really mental health stigma. And so the Tell You a Story Project was designed to really improve our understanding of mental health stigma amongst refugee men and also to take steps to try to reduce this stigma and increase help-seeking.
This project focused on men from Arabic-, Farsi- and Tamil-speaking communities. The first stage of the project really involved trying to deepen our understanding of mental health in these communities.
Participants in the Tell Your Story program were randomly assigned to either complete the 12-session online program or to a waitlist control group. They were assessed at baseline, immediately after they finished the intervention, which took about a month and then a one-month follow up.
What we saw was the men who completed the Tell Your Story intervention showed significant decreases in self-stigma related to PTSD, and also significant increases in the amount of informal help-seeking that they did. They were more likely to talk to family, friends, a spouse, a parent about their psychological difficulties than those in the waitlist control group. We also saw that amongst people who completed the intervention, the more modules they did, the more new sources of help that they engaged with in the subsequent month.
Tell Your Story was the first intervention targeting mental health stigma in refugees that's ever been done worldwide in an online capacity so that's really exciting, but I think this project is really just the starting point; the beginning of our understanding of how mental health stigma impacts our help seeking in refugee communities. There's a great deal more work that could be done to really try to understand these factors amongst these very vulnerable, traumatised, and displaced people.
Chanh Mann, Manager, Projects and Partnerships, Incolink, Melbourne:
Contact and Connect is a smartphone-based intervention program that is targeted at construction industry workers to reduce stigma associated with shame, self-blame and help seeking inhibition. The goal is to deliver contents, and information, and education via an SMS.
Teri Cooper, Project Coordinator, Incolink, Melbourne:
They would get a message on their phone, "Hi, John." "Hi, Jack." It was always personalised. “We've got a program.” "Are you unemployed? If so…," and then they would click on a link with a little bit of information about the program, and a very straightforward signup form.
Chanh Mann:
What we find is that narrative-based content is quite powerful because it allows people to make their own personal connection to these stories and then from there to provide them information that would help them to seek help or [00:10:00] to make the connection to what they are experiencing in their own lives.
Teri Cooper:
Because the intent of the program was that people would go through the program and their levels of stigma would reduce. We did find that. We did find that there was a level of reduction. Then there was also a surprising finding such as younger people tended to have more self-blame and resistance to help seeking, whereas older people tended to have more self-shame. The other thing was that unemployed and employed people had virtually no difference in their stigma levels. They did have a difference in their suicide ideation. You would expect unemployed people would probably have a bit more of that, which they did, but there was virtually no difference in the stigma levels.
Nearly 20 per cent of those who went through it contacted a mental health practitioner or Incolink’s counselling services, or online resources after they finished in order to help themselves. Over 45 per cent of them gave advice to someone they care about or a colleague in order to direct them to someone who could help them. Now, they felt a bit more empowered and a bit more... yeah, not afraid of talking about it.
Chanh Mann:
I think with a construction industry, you have people who are very genuine and authentic in their life. What you see is what you get. So therefore, the expectation is that when you come to them and have this conversation, if they can't connect to that story if the language is too jargonistic then you won't have that connection. That authentic voice, it has to be in their voice. That's why we were keen to get the workers involved who were telling their own story in their own language because without that they wouldn't even participate in the program.
Brent Hedley, Mental Health and Wellbeing Manager, Australian Football League Players' Association, Melbourne:
Better Out Than In was a digital campaign featuring real-life stories of AFL players, past and present, AFL coaches and construction workers. The focus of this campaign in particular was on hearing real life stories of guys who had dealt with depression and anxiety at various times in their life either personally or through their experiences with others. And I guess showcasing the positivity through the openness, acceptance and hope of having revealed their stories through the process.
The common denominator we were looking to reach was really challenging, I guess, or reframing, the conversation around the hyper-masculinity that exists within those particular workplaces, and I guess the norms around the shame, secrecy and stigma associated with depression, anxiety and mental illness.
Yeah, we invested heavily in the content itself, so the stories themselves. I guess one of the challenges that we faced in light of that was putting a, I guess a process in around sharing that via various media forms, both traditional and social, and, I guess, really opening that up to a broader reach and accessibility.
In terms of results, it was a fairly confirming, I guess, process. We saw behavioural changes amongst this particular group of men in the sense that the ambassadors that featured as part of the campaigns are now reporting back into us in terms of the kind of contact that they're receiving on a personal level through digital channels on the basis of having shared their stories. In addition to that we had a lot of feedback from, I guess, members of the general community either A, exhibiting their support for the project but B, looking to get involved with it in some way, shape or form.
Craig Gear, Director, CGA Consulting, Sydney:
YFronts was an idea originally from Damien Bonson, who's a guy who lives in the Broome area. Having seen the impact on FIFO workers, that's the Fly-in fly-out workers that are in that mining sector, speaking about the struggles that it was being away from home, socially disconnected from their families. He came up with this idea of trying to create something, a virtual community that would bring people together, being able to have then a platform, a digital platform that started to drop in wellbeing information and, through that, to reduce the stigma around mental health. That was able to lead us into when we actually were awarded the project and started researching what people were doing, to actually put out some validated tools around stigma. So the depression and stigma scores, and also what people were thinking about their work colleagues as well, and whether they would seek help.
The other thing we started try and build into that was an approach to wellness. So, we had eight domains of wellbeing, and looked at those, and scored people on that, which allowed us to, then, do a pre / post [assessment] once we had the app there, about the impact, not just on stigma but on wellbeing as well.
In the end, though, once that app was out there and people started using it and talking, it was more that social connection and connecting that people were feeding back and saying, "This is really good." It was probably too early to see the changes in stigma reduction. What we did see, though, is an improvement in wellness and the wellness scores. We’ve started the conversation and people have said, "I'm much more aware now. I'm much more aware of talking about my anxiety, my depression." Lots of people started opening up and we’ve just got to keep them talking.
Andrew Thorp:
The Initiative had six projects. They all had different target audiences. They all used different methodologies to reach that audience and to engage with them.
Success is really dependent upon having a clear theory of change, and increasingly, I think we're going to have to focus our evaluation on behaviours we're wanting to see. Are people more likely to have the conversation? Are they actually having the conversations? What are the outcomes of those conversations? Are they going seeking support? Visiting a website? All these behavioural elements are the things we're going to have to measure a lot more than attitudes.
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