The burden of mental illness makes the need to create awareness and acceptance of affected persons in the populace more urgent [1]. Stigma and discrimination have been recognised as a major barrier to helping individuals with mental illness as well as their families [2].
Corrigan and colleagues identified protest, contact, and education as three major strategies for dealing with psychiatric stigma and discrimination [3].
Protest strategy is often described as a responsive approach that aims to challenge misrepresentations and negative beliefs about mental illness projected by the media and accepted by the public, but not necessarily replacing these unfavourable expressions with positive and factual information about mental illness [4]. Research has shown that anti-stigma strategies using protest have been effective but may have potential rebound effects [4–6].
Education strategy aims to provide factual information about mental illness and has been shown to improve the attitude of its target audience towards persons with mental illness, howbeit; the effects may not be sustained for a long period of time [7].
Contact strategy provides a platform for the public to meet and interact with persons with mental illnesses who are doing well on their jobs and are able to interact well with their neighbours [5, 8–10].
Most interventions aimed at improving the public’s perception of persons with mental illness have utilized one or more of these strategies while adjusting them to suit the target group. A meta-analysis of data from a total of 38,364 respondents recruited into 72 different studies which were conducted across 14 countries revealed that adolescents were more likely to be influenced by education strategy while adults were more like to be influenced by contact strategy [4]. There was no definitive report about the effect of protest strategy.
An uncontrolled intervention in selected secondary schools in the United Kingdom (UK) employed the use of contact and educational strategies to improve pupils’ perception of mental illness [10]. In the UK intervention, a total of 472 pupils received lectures, which included sessions delivered by a person who had experiences of living with mental illness [10]. At baseline, 1 week and 6 months follow-up, respondents completed a questionnaire that assessed their factual knowledge of, and attitude to mental illness on a Likert scale of “agree” “disagree” and “unsure”. Respondents’ desire for social distance was rated “definitely”, “probably”, “probably not”, “definitely not” and “not known”. Researchers reported significant changes across the three scales assessed at 1 week post intervention and these changes were sustained at 6 months follow-up [10].
Another study carried out in middle schools in the United States of America (USA) utilized educational strategies and incorporated activities such as games, poems, and storytelling [11]. At baseline, immediate post-intervention and 6 weeks follow-up, all respondents were required to complete questionnaires that assessed their knowledge of, and attitude towards persons with mental illness on a Likert scale of 5 from “strongly agree” to “strongly disagree”. Similarly, participants’ desire for social distance from persons with mental illness was measured on a Likert scale of 5 from “definitely unwilling” to “definitely willing”. Each of the questions on the knowledge, attitude and social distance scales were scored 1–5 based on the Likert scale and were such that higher scores on any of the 3 categories indicated accurate knowledge, positive attitude and favourable disposition towards persons with mental illness respectively. Responses from a total of 193 pupils were analysed; 87 in the control and 106 in the experimental groups. Findings from this study showed significant positive changes in the pupils’ mean knowledge, attitude and social distance scores at immediate post intervention [11]. These changes were sustained at 6 weeks post intervention.
A few intervention studies have also been carried out in developing countries. For instance, in rural Rawalpindi, a school mental health programme was developed to increase awareness about mental disorders and available treatment services [12]. The direct target group of the programme was school children who were required to share the information they were receiving with a parent, a neighbour, and a friend that did not attend the same school. The mental health programme incorporated activities such as lectures, short plays and skits, poster-paintings and essay writings [12]. Rahman and colleagues evaluated the impact of this school mental health programme on 50 school children aged 12–16 years in a rural sub-district of Rawalpindi who had been exposed to the programme for 4 months, and another 50 who did not receive the mental health training [12]. A 19-item questionnaire was used to assess mental health awareness of participants at baseline and 4 months post-intervention. Each item was rated on a scale of “yes”, “no” and “don’t know”, and for analysis, a score of “1” was assigned to every correct answer, “0” to incorrect and “don’t know” answers [12]. Researchers reported highly significant differences between the intervention and control groups such that schoolchildren who received the intervention, as well as their parents, neighbours, and friends all scored about five points higher than their counterparts in the control group [12]. Researchers also reported significant changes in the mean scores of school children in the control group and their friends, but this was minimal compared to the changes observed in the intervention group. The significant change among the control group was attributed to the fact that the questionnaire may have stirred up the desire to know more about mental health and thus personal enquiry into the subject matter [12].
Another intervention carried out among 78 secondary school pupils with a control group consisting of 76 students in Nigeria, utilised a single contact 3-h mental health training consisting of lectures and discussions [13].
Using an adapted questionnaire version of the UK Pinfold study, participants’ knowledge of, attitudes and social distance towards persons with mental illness were measured at baseline, immediate post-intervention, and at 6 months follow-up [13].
There were nine (9) knowledge and five (5) attitude items which were rated on a scale of “agree”, “disagree” and “not sure”, a score of 2 was given for each correct answer, 1 for “not sure” and 0 for the wrong response [13]. For the social distance scale, the five answer options were recoded into three by combining “definitely” and “probably” into a category and “definitely not” and “probably not” into another while “don’t know” was left as a separate category. Similar to the knowledge and attitude scales, a score of 2 was then assigned to correct responses, 1 for “don’t know” and 0 for a wrong response [13]. Researchers reported a significant increase in the mean knowledge score of participants in the study group compared to participants in the control group at immediate post intervention (11.4 vs. 9.5; p < 0.001), and this change was sustained at 6 months follow-up (11.3 vs. 9.3; p < 0.001) [13]. Researchers, however, suggested the need for intervention studies with longer duration and multiple training sessions to provide participants with more time to assimilate and internalise the training content; hence, resulting in a change in attitude and a reduction in the desire for social distance from persons with mental illness [13].
The use of role-play has been identified as an effective means of changing attitudes and challenging public views about stigmatising conditions such as HIV/AIDS [14]. It has also been found to achieve sustained positive behaviour and change, [15–17] but remains an unexplored intervention to improve perceptions of mental illness among school pupils in Nigeria. Therefore, the current study involved the conduct of a mental health training of three sessions over 5 h to challenge school pupils’ knowledge of mental illness, attitude and social distance towards persons with mental illness. The training programme included didactic lecture sessions, group discussions, and role play.