Healthcare professionals’ perspectives on a mental health educational campaign for the public

Introduction

Public knowledge of steps necessary for the early detection, prevention and treatment of major physical diseases is accepted as an important measure in the healthcare system. In disorders such as cardiovascular diseases, infectious diseases and many others, the public are often aware of early warning signs, means for prevention and the appropriate sources of healthcare professionals available. People may even be familiar with some of the medical and complementary treatments and the anticipated benefits that such treatments may bring. This knowledge base is a result of significant investment in educational campaigns and resources to deal with many different diseases and health conditions. The same, however, cannot be said for mental health disorders. Depending on the community, members of the public may be ignorant on how to recognise the early signs and symptoms of mental health disorders, how they may be triggered or where they can seek help. External factors such as culture and stigma also play a significant role in the lack of public knowledge of mental health disorders (Gulliver et al., 2010; Rickwood et al., 2005).

Research on public knowledge and beliefs about mental health disorders was a neglected area until the concept of mental health literacy was brought forth in the late 1990s. Mental health literacy may be defined as ‘knowledge and beliefs about mental disorders which aid in their recognition, management or prevention’ (Jorm et al., 1997). Knowledge of mental health disorders could serve as a link to the need for action in order to achieve the benefit to a person’s own mental health. Knowledge of how to prevent mental disorders, recognition of when a disorder is developing, knowledge of help-seeking options and treatments available, knowledge of effective self-help strategies for milder problems and first aid skills to support others who are developing a mental health disorder or are in a mental health crisis are all identified components of mental health literacy and potential targets for public education (Jorm, 2012).

Education in mental health is becoming a focus in many countries as reduction of stigma linked to mental health disorders is an important goal for national healthcare strategies. In Qatar, the National Mental Health Strategy identifies mental illness as a national priority and was developed with the goal to promote good mental health and wellbeing (Qatar National Mental Health Strategy (QNMHS), 2013). Public education is central to this strategic approach in order to reduce the prevalence and impact of mental health disorders. The strategy identifies that awareness campaigns and information resources need to be developed to improve mental health literacy of the population and promote good mental health and wellbeing. To develop these initiatives, this strategy also states that further research must be conducted to better understand attitudes towards mental health in Qatar, the specific barriers to seeking help and how positive attitudes and behaviours can be enabled and encouraged (QNMHS, 2013).

In mental healthcare, interprofessional collaboration has significant value due to its ability to facilitate and coordinate the provision of care from a variety of experts to patients with dynamic and complex health and social needs (Onyett and Ford, 1996). Besides the direct value to patients with mental health disorders, healthcare practitioners also have a unique perspective on the importance of mental health education to the general public and to their individual patients. However, there is a gap in knowledge about the perceptions and opinions of mental health practitioners regarding the public’s mental health literacy. Furthermore, little is known about different healthcare professionals’ perceptions with regard to the application of public mental health education campaigns in Qatar. This study presents findings from part of a larger study exploring healthcare providers’ perceptions on shared decision making and interprofessional care in mental health. One of the primary objectives of this larger study was to summarise the views of different healthcare professionals involved in mental health care for development of a comprehensive plan for public education program about mental health care. This report aims to explore barriers and facilitators to implement an educational campaign in mental health for the public in Qatar.

Methods

The data in this qualitative study were collected from healthcare settings within Doha, Qatar. Participants in the study included healthcare providers from a range of different professions as well as healthcare administrators. Purposive sampling was used to recruit healthcare providers, but as some providers suggested other colleagues to approach, a snowball sampling was also used. Healthcare providers from all professions enrolled in this study had to have had direct experience with providing care to mental health consumers. The research team members ensured that providers from a variety of different professions and specialties from multiple healthcare settings were approached to take part in this study. Written informed consent was provided to all participants prior to enrolment in the study. Participation in the study was voluntary.

Semi-structured interviews with individual healthcare providers were conducted between March 2015 to January 2016. The open-ended questions which explored healthcare providers’ opinions of mental health education and understanding within the general public were extracted from the interview guide that was developed for the larger study exploring the concept of shared decision-making and interprofessional collaboration in mental healthcare.

Examples of interview questions are as follows:

All interviews were conducted in English by the corresponding author at the healthcare providers’ site of work or at the author’s institution (Qatar University). English was selected as the language for interviews as all documentation in the healthcare system in Qatar must be completed in English. Interviews were audio-recorded for transcription purposes, and field notes were taken to support the interpretation of transcripts. All but three interviews were transcribed on the same day the interviews took place, while the remaining transcripts were completed within 72 hours of completion of the interviews. Data relating to the study were stored on a password-protected laptop dedicated to the study for the duration of 3 years. All healthcare providers consented to having their interview audio-recorded. The interviews included in this study were completed between 18 and 31 minutes. Once investigators felt that data saturation had taken place, no further interviews were conducted.

All audio recordings were transcribed verbatim. Verbal data were analysed qualitatively to explore themes healthcare professionals used when discussing mental health education for the general public. In order to be comprehensive and establish complete analysis and interpretation of the data, an inductive content analysis was used (Thomas, 2006). Headings and notes were identified within the text during multiple readings of transcripts using an open thematic type of analysis that was completed independently by two investigators. Categories and keywords from the coding were then grouped under higher order headings (Burnard, 1991, 1996). An abstraction phase then followed in order to formulate general descriptions of the research topic through categorisation (Burnard, 1996). Healthcare profession and setting were also used to classify and evaluate the data. The research team met regularly to discuss emerging themes and solutions to emerging challenges. Discrepancies in coding were solved by consensus. NVivo software (Version 10, QSR International) was used to assist in data organisation and analysis.

Ethical approval for this study was obtained from Hamad Medical Corporation and the Qatar University Human Research Ethics Committee.

Findings

Forty healthcare providers were approached to participate of whom 35 accepted. Those who did not take part did not respond to our invitation. The participants in the study came from a variety of healthcare backgrounds and practice settings (see Table 1).

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Table 1.

Participant demographic details.

Demographic characteristics	Number (n) = 35
Gender
Male	13
Female	22
Profession
Psychiatrist	2
General practitioner	7
Nurse	9
Pharmacist	13
Psychologist	1
Dietitian	1
Administrator	2
Specialisation
Mental health specialty	18
General health specialty	17
Healthcare setting
Hospital	25
Primary care	10

Four major themes (Message, Avenues of Education, Media/Organizations and Culture) were identified with regard to healthcare providers’ perceptions on mental health education for the public. Each of these themes and subthemes are discussed.

Perceptions of message to be delivered to the public through mental health education campaigns

Healthcare providers of different professions openly discussed their opinions of what would be an appropriate focus for a message when educating the public about mental health.

Participants subcategorised the idea of an educational message into the following: pathway to care, identification of mental health disorders and patient integration. The message of ‘Pathway to care’ was identified as a means to have the public understand that services for mental health disorders do exist and how they might access those services:

Most people don’t even know where the psychiatric hospital is. We must first bring recognition to where patients with mental [health] disorders can go for treatment and who they can see. Maybe a psychiatrist, psychologist, or social worker. Mixing mental health services at other clinics would help in patients knowing where they can access help. (Respondent 14 (P14); pharmacist, hospital)

An understanding that patients may not even know what the first step in the care process is and where to go was evident:

The pathway to care is important for [people] to know. Do they need to see a primary care physician first or go directly to a tertiary care center? Once they see us for the first time we can follow up with them but if we don’t see them to begin with, they may never get the treatment they need. (P4; psychiatrist, primary care)

There was some concern about lack of public understanding of pathways to care and the services delivered by psychiatric institutes. This was thought of as an opportunity as patients who are effectively treated could describe their care process. If positive patient experiences and outcomes were more widely known about, others experiencing similar issues might be more likely to seek similar care:

… all our effort is according to our facility so the problem is we need more. One of the main problems is that people in the general public don’t even know where the mental health hospital is and how they can access the services here but they will all know where the general hospital is. Nobody knows what we are doing here. If someone is treated well and is able to go back to the community to work no one ever hears about it or knows about it. (P8; nurse, hospital)

While the route of access to care appeared to be a rather simple message for public education, creating an understanding of the causes of mental health disorders was noted to be more difficult. The suggestion that public education on mental health may need to begin on a smaller, more appropriate scale:

Misunderstanding of the diseases in mental health and the medications needs to be addressed. Providing information to the families that these diseases are not the fault of the patient is a start because this is still an issue that we face. (P7; pharmacist, primary care)

Discussion about the details that would be addressed with participants during an educational session with the public differed between the healthcare professional being interviewed. For some, self-recognition of symptoms was an appropriate message that would provide some basic knowledge for the public:

I think raising awareness about certain diseases within mental health such as bipolar. This would include educating about early signs, symptoms, the importance of early treatment, and the importance of early visits to physicians. Even if it’s not a high risk population, anyone in any family could be diagnosed. (P20; pharmacist, primary care)

Other healthcare providers suggested that more general aspects of disease awareness should be covered in a public educational programme:

Helping people understand that things like depression can affect anyone is important first message. We should start here before giving too much information. (P18; administrator, hospital)

Several healthcare providers described a specific type of message that could be effectively delivered through the media to bring about awareness of mental healthcare:

… success stories would be beneficial. Real patients could tell how they were suffering but were able to get help and say how they got the help. (P3; psychiatrist, hospital)

Perceptions of public education in mental health care

Healthcare providers described many scenarios of how a public education programme could work to enhance the message being delivered to the appropriate group. Incorporating education on mental health with lessons on physical health in the school curriculums might allow for a better understanding of mental disorders and in turn, reduce stigma:

I think we should start from the schools. In the primary and secondary schools [mental health] can be part of the education curriculum in general health. Especially as they enter the phase of puberty that they understand what’s the difference between normal changes and symptoms of a mental health illness. (P32; nurse, hospital)

Another point brought forward was early education, particularly in young children, as it could further benefit in delivering an understanding of tolerance in an attempt to remove stigmatising behaviours towards people suffering with mental health disorders:

… introducing young children to [people with mental health illness] and making them more accepted in society gives the message that these people are normal and should be treated normally. (P19; pharmacist, primary care)

The concept of setting up a healthcare booth to discuss mental health disorders openly with the public was mentioned by one healthcare professional. However, this provider suggested that integration of a booth focused on mental health with other booths could reduce the feelings of being singled out and may improve a persons’ likelihood of approaching for information:

Well in terms of booth I don’t mean it’s separate because at the conference what they have is a station for checking your diabetes, a station for checking your cholesterol, and you don’t even know what it is until you walk up there. So what you can do is have brochures about the difference between the blues and actual depression and the resources at the back which they can contact themselves and therefore it eliminates other people judging you or seeing what you’re doing. It’s between them and you and then if they have any further questions, they can either have a person to contact or if there’s no one there at the time they can just ask whoever is there at the booth. Bringing mental health together with other diseases sends the message that it is part of overall health and doesn’t need to be singled out. (P35; nurse, hospital)

When discussing an appropriate setting to start a public education campaign in mental health, the university was identified as possible location. Students educated in universities could potentially then go to their families and pass on messages of mental health education, thus, a message aimed at reduced stigma could reach others not attending an educational institution. One healthcare professional suggested limiting the target population initially rather than developing an educational campaign for the general public:

Written communication in places like universities. This is the place where education happens. This is where the discussion would start to happen. Don’t start with everyone. Start with a targeted audience and then if it works it could be expanded. (P28; dietitian, primary care)

Perceived influence of media, societies and organisations on mental health education

When discussing modes of education delivery, many participants described how the media in general could be used for message delivery as well as to reach a larger audience. The media was viewed as comprising a set of collective communication outlets or tools that could be used to deliver information or data. This was inclusive but not limited to television, newspaper, mobile devices (i.e. smartphones), the World Wide Web and radio broadcastings. The potential of media in public education was described by several practitioners:

… use social media to make [mental health disorders] more acceptable before jumping in to something more in-depth. Social media is useful to give the simple, general message. Anything online is a great tool as most people have access in their own homes and any education programme could reach them in the privacy of their home. (P29; pharmacist, hospital)

Everybody has a phone, even children, and I think being able to tap into that, like a new phone app or some sort of advertisement … of mental health awareness will be very effective. Especially because if children are taught at a young age that, you know, mental health happens, it’s just the same as us, you know, catching the flu just to raise that awareness that it can happen to anybody or is happening right now to somebody right beside you. It would really help remove the stigma in this culture. (P35; nurse, hospital)

One healthcare provider suggested a broad approach to media delivery of public messaging in mental health:

We have to do psychoeducation through the media. Through the television and newspaper and we have to give some lectures to the school students and wellness camps. Yes, camps to inform them of the mental illness and bring awareness of what is mental illness. What is the future of these mental health patients? What are the available methods of treatment? How far they are producing new medicines which are more effective and with less side effects they have to inform, know that. Most of the patient or most of the families they have all believe that mentally ill patient is a stigma. We have to delete this stigma. (P3; psychiatrist, hospital)

Besides the media, societies and organisations involved in mental health awareness and treatment were viewed as potential avenues to deliver such public education. It was suggested that these resources could not only be used for education but could also reduce the negative stigma present around patients with mental health disorders:

… creation of societies that advocate for mental health. I think that would tackle a bit of the stigma and [negative] public perceptions of mental health so that they can start seeking help and access resources. (P4; psychiatrist, primary care)

I don’t think there are enough clubs … We need places where these people can go and feel safe. This would be a great place to provide education for people. (P6; psychologist, primary care)

Perceived cultural aspects of public education in mental health

The concept of the cultural influences on public education in mental health emerged from discussions with healthcare providers. Stigmatising beliefs and actions were described to varying degrees as negative, impacting on the ability to effectively conduct any form of mental health education programmes with a large audience:

Stigma is everywhere, in community and even some health care professionals have stigma towards mental health disorders. They should show how common mental health is and that some of the most prescribed medications are for mental health so it’s not just about cardiology and other disease states. (P15; pharmacist, hospital)

The problem also in the community is that we have stigma about psychological problems which results in under reporting of this conditions. (P24; physician, general practitioner, hospital)

Many healthcare providers commented on educational programming while addressing the cultural aspects of stigma in mental health disorders. One medical practitioner discussed some of the external influences that should be taken account of in order to effectively deliver any form of mental health education to the public:

you need to tie culture and religion to educate the people and eliminate stigma associated with mental disorders. Cultural icons will make greater impact than health care professionals. (P9; nurse, hospital)

In a socially diverse country like Qatar, one participant stressed that the issue of culture cannot be applied to the general population because that population is made up of so many different people from all over the world. This problem needs to be addressed when designing a local public education campaign in mental health:

I can say even across different races it’s difficult to [educate about mental health]. Across different races I don’t know where to start from. For a general population [like Qatar] it’s difficult. In an individual this is easy but in a general population, it becomes a problem. (P22; pharmacist, hospital)

Several healthcare providers were concerned that education that focused on individuals may fail in a community where the family as a whole unit holds so much importance. Any education focused on educating the public should seek to educate the family as a unit rather than single out individuals:

I think here it has to be all family based because everything happens through the family. Anything a health care professional says could be countered by a family member. If the family as a unit is educated, decisions could still involve the family but it would be supported with education. (P26; physician, general practitioner, primary care)

Discussion and conclusion

This article provides a description of how a range of healthcare providers in mental health perceived aspects of educational programming in mental health targeting the general public. The findings of this study, while highlighting the broader context of public education, also reveal individual and cultural features that need to be considered during programme development. As educating the general public on mental health is complex and multifaceted, it is important to consider the views and opinions of healthcare providers from a variety of specialties and healthcare settings to gain an understanding of an informed approach to educational programming.

Healthcare providers in this study talked about a variety of messages that they felt should be delivered at a mental health public education platform. One common theme that emerged was the importance of educating the public about how individuals with mental health issues may seek help. In a survey by the World Health Organization’ World Health Initiative of 28 countries, only a minority of patients needing treatment for mental disorders such as depression, anxiety and substance abuse had actually received treatment (Wang et al., 2007). Of those who did eventually receive treatment, delays in implementing such treatment ranged from 1 to 30 years, depending on the type and severity of the specific diagnosis. Although various factors which influence a person with a mental health disorder seeking help have been reported, one A critical factor that has been identified is the individual’s inability to recognise early signs and symptoms of the mental health problem (Gulliver et al., 2010). Previous research findings, while country dependent, have suggested that under-recognition of mental health disorders is common and also that labelling patients with a particular disorder could lead them to believe that they are able to deal with the disorder on their own (Jorm et al., 2005, 2006b; Kermode et al., 2009; Pescosolido et al., 2008). The knowledge of symptom self-recognition must also be incorporated with knowledge of the variety of healthcare professionals who provide mental health services. These professionals should be viewed in the manner of high standards of training, clinical practice, professional conduct and confidentiality in order to build and maintain a trustworthy relation with the public. Views of such professionals vary depending on the country of setting with the results from some studies suggesting that the information on mental health disorders given from friends and family is often trusted more highly than that given by healthcare professionals (Cotton et al., 2006; Jorm et al., 2000, 2005). However comforting and well-intended, advice on a mental disorder taken from a family member or close friend instead of that given by a trained professional may lead to detrimental outcomes. Respondents in this study, representing mental healthcare providers in Qatar, also recognised the importance of self-recognition and pathway to care making the recommendation that public education in mental health should target these messages.

Another important aspect which was brought up by the healthcare providers was the need to reduce or eliminate stigma through mental health literacy. Stigma has been defined as lack of knowledge (ignorance), negative attitudes (prejudice) and associated negative behaviours (discrimination) towards a group or individual due to real or assumed characteristics (Corrigan and Watson, 2002; Thornicroft et al., 2008). When discussing strategies to reduce stigma, respondents in this study were likely referring to interventions to improve the public’s lack of knowledge about how a person with a specific mental illness acts as a consequence of such illness and to the behaviours and attitudes as they try to relate to this person. Within the context of mental health literacy, educational interventions can thus be viewed as the most appropriate approach to reducing mental health stigma. However, it has been argued that producing shifts in deeply ingrained attitudes and behaviours requires a multicomponent approach (Corrigan and Penn, 1999; Rüsch et al., 2005). Thus, mental health literacy interventions are more likely to reduce stigma if accompanied with other strategies that also address prejudice and discrimination (Corrigan and Watson, 2002; Rüsch et al., 2005; Thornicroft et al., 2008).

There is encouraging findings from several studies that over time mental health literacy, including perceptions of mental healthcare providers, has been improving among the general public (Goldney et al., 2009; Jorm et al., 2006a; Mojtabai, 2007). Although the precise reason for such a change of mindset remains elusive, specific interventions within the community may be leading this change. Examples of educational campaigns with positive outcomes which have been designed to target a variety of communities as well as those delivered online can be found in the literature. In a high school setting, studies have found that lessons about mental illness and avenues for assistance provided by trainee psychologists have had a positive impact on students’ help-seeking behaviour (Battaglia et al., 1990; Esters et al., 1998). A review by Wells et al. (2003) provided evidence that universal school mental health promotion programmes could be effective with long-term interventions aimed at changing school attitude in having a more positive impact compared to brief class-based programmes. Through a Grand Challenges Canada funded initiative called ‘An Integrated Approach to Addressing the Issue of Youth Depression in Malawi and Tanzania’, Kutcher and colleagues culturally adapted a previously demonstrated effective Canadian school mental health curriculum resource for use in Malawi, and evaluated its impact on enhancing mental health literacy for educators (teachers and youth club leaders) in 35 schools and 15 out-of-school youth clubs in the central region of Malawi. Results demonstrated a highly significant and substantial improvement in knowledge and attitudes pertaining to mental health literacy in study participants (Kutcher et al., 2015). Healthcare providers interviewed in our current study also recognised the importance of early mental health education taking place in the classroom.

Community wide educational campaigns in several countries have demonstrated significant outcomes in the improvement of mental health knowledge (Dumesnil and Verger, 2009). One such campaign in Australia, known as beyondblue, aims at ‘equipping everyone in Australia with the knowledge and skills to protect their own mental health’ (Hickie, 2004). Along with raising awareness of such mental health disorders as depression, anxiety and suicide, this web-based educational programme has also expanded its work to include sub-populations as children, young adults, older adults and multicultural communities to name a few. A recent systematic review identified nine studies which investigated the effectiveness of Internet-based resources aimed at improving help-seeking behaviour among young people (Kauer et al., 2014). Using various methodologies, some, but not all of the articles identified in this review found that resources available through the World Wide Web had a positive impact on help seeking behaviour in young adults (Kauer et al., 2014). When compared to controls, a website aimed at providing information about mental health disorders, such as depression, was shown to increase a participants’ knowledge of treatment alternatives (Christensen et al., 2004). With a clear and targeted objective for an online, educational programme for the public, achievable and measurable outcomes can be collected to demonstrate the benefits. A study by Taylor-Rodgers and Batterham (2014) evaluated a brief online psychoeducational intervention aimed at increasing positive attitudes towards help-seeking behaviour. The study compared outcomes in a group of participants that were assigned to receive online psychoeducation on depression, anxiety and suicide with a group that were assigned to an online attention-matched control. The primary outcomes included mental health literacy, mental illness stigma and attitudes toward professional help seeking and were measured before and 3 weeks after each intervention. The online psychoeducation produced increased anxiety literacy, decreased depression stigma and increased help-seeking attitudes demonstrating the effectiveness of an online educational intervention (Taylor-Rodgers and Batterham, 2014). The importance and utility of these online educational modules in mental health were echoed by the mental health providers interviewed in this study.

Challenges that the culture of a community can bring to varying aspects of mental health was clearly discussed by healthcare professionals in this study. The struggle between concepts of Westernised medicine and traditional practices can be fierce, particularly in a region undergoing extensive change to its healthcare system to more closely resemble that seen in Western countries (Qatar National Vision 2030, 2008). One respondent suggested that the stigma brought about from mental health disorders does not only affect the individual facing the disorder but also their family and friends who may distance themselves from this individual for fear that the community at large may view them differently as well. Much of this stigma and misunderstandings often comes down to a lack in mental health literacy. Mental disorders in some communities may be seen as being due to curses, spirits, bad karma or divine intervention, often leading to individuals and those trying to offer help feeling helpless (Lee et al., 2010). This may sometimes lead to non-evidence-based interventions being sought rather than established evidence-based treatment alternatives (Lee et al., 2010). Qatar also offers a unique challenge in that a large portion of the population is ex-patriates from developing countries. Some evidence has suggested that in developing countries where western healthcare services are limited, traditional practices of medicine may delay or inhibit the help-seeking behaviour for established treatments (Petersen et al., 2011). In some circumstances, the model offered by traditional medicine could be considered, by some, to be discriminatory or an abuse of human rights. Aspects of an educational campaign that aims to reduce stigma educate on where help for mental disorders can be found, and take into account other cultural barriers that need to be considered in a region with a vastly diverse population.

The use of individual interviews with a variety of healthcare professionals provided the opportunity to identify unique and circumstantial information on what would be important concepts to consider when developing a mental health public education campaign. The current study however does have several limitations. First, all interviews were conducted in the English language and many of the healthcare professionals interviewed did not speak English as a first language. It is possible that some participants may not have fully understood questions they were being asked when providing responses or felt uncomfortable elaborating on their responses. Second, this study was conducted solely in Qatar while a majority of healthcare providers interviewed received their training outside of the country; it is unclear whether these factors may be comparable to mental healthcare providers practising elsewhere. Third, participants in our study did not equally represent all healthcare professionals in mental health in Qatar. The perceptions of some professions, including social workers and occupational therapists, were not captured in our results. Opinions from these healthcare professionals would be valuable when preparing a mental health campaign for the public. Finally, as the findings in this report were part of a larger study investigating the perceptions of shared decision making and interprofessional care in mental health, it is possible that the investigators may have not discussed all issues in sufficient detail related to a mental health education campaign for the public. Nevertheless, this topic was spontaneously brought forth in most of the interviews as healthcare providers appreciated its importance in relation to effective shared decision making and interprofessional care.

This qualitative analysis has provided some strategies and considerations that should be considered and understood when developing a public mental health education campaign. Cultural aspects appear to pose a significant barrier to the development and functioning of an effective public education campaign in mental health. Further research is needed to compare the effectiveness of different mental health educational campaigns. It is also important to pilot educational campaigns and collect consumer feedback to understand their opinions and perceptions of the potential positive change each could bring.