Evaluating the Effectiveness of Mental Health First Aid Program for Chinese People in Hong Kong

Abstract

Purpose:

Chinese people generally lack knowledge of mental illness. Such phenomenon may lead to a delay in seeking psychiatric treatments. This study evaluated the effectiveness of Mental Health First Aid (MHFA) program in improving mental health knowledge of the general public in Hong Kong.

Methods:

A quasi-experimental design was adopted whereby 138 participants received MHFA training and 139 partook in seminars on general health, respectively. All participants filled out a standardized questionnaire before, at the end, and 6-month after the training.

Results:

Findings demonstrated that MHFA training might be effective in enhancing participants’ knowledge of mental disorders, reducing stigma, and improving perceived confidence in providing help to people with mental illness. Effect size statistics revealed mostly modest to moderate improvements in major variables in the experimental group.

Conclusion:

It is recommended that culturally attuned MHFA program can be used as prevention strategy to promote good mental health in Chinese communities.

Keywords

mental health first aid mental health literacy Chinese depression schizophrenia

Epidemiological studies on the help-seeking behaviors of different cultural groups have consistently revealed that a large number of Asian people with a mental illness, including Chinese, often experienced a much longer delay in help-seeking than other ethnic groups in different societies (Burnett et al, 1999; Ryder, Bean, & Dion, 2000; Skeate, Jackson, Birchwood, & Jones, 2002), and the duration of untreated mental health condition could be as long as 1 to 2 years. This is a serious issue that warrants intervention because individuals with a longer duration of untreated mental health condition were likely to be less responsive to treatment in general and required more resources and long-term intensive intervention (Edwards & McGorry, 2002). On the other hand, a growing body of clinical evidence suggests that early detection and intervention could result in a substantial reduction in morbidity and in better quality of life for these people and their families (Black et al, 2001; Edwards & McGorry, 2002).

In Hong Kong, the prevalence rate of mental disorder ranges from 15% to 25%, and the incidence rate of severe mental illnesses varies from 1% to 3% (Hospital Authority, 2010). With the current population reaching seven million people, it is estimated that there are 1.05 to 1.75 million people potentially suffering from different types of mental disorders in Hong Kong. Unfortunately, only a small portion of these individuals seek and receive psychiatric and psychological treatments from the mental health professionals (S. Lee, Tsang, & Kwok, 2007). Identifying and treating these individuals at the early stage of the development of their illnesses have become an important prevention strategy of any public health initiatives.

Mental Health Literacy as an Important Factor Influencing Delay in Treatment

A number of factors have been identified to be associated with a delay in seeking help from formal psychiatric professionals among Chinese people. These include the influence of the informal network (Kramer, Kwong, Lee, & Chung, 2002; Pearson, 1993), stigmatization (Hong Kong Council of Social Services & Mental Health Association of Hong Kong [HKCSS & MHAHK], 1996; Kramer et al., 2002), and knowledge of mental illness (Wong & Li, 2014).

Studies have suggested that there is usually a sequence of contacts from lay system to professional system and that those who endorse the lay support system in the first place would seek help from the professional system only if the lay support system as a source of help is exhausted (e.g., Addington, Mastrigt, Hutchinson, & Addington, 2002). Within the lay system, overseas studies have found that friends are the most critical source of help, followed by family members and self-help groups. In the professional system, the family physicians are identified as the most important helpers in the help-seeking process, to be followed by psychiatrists and psychologists.

In Chinese culture, informal networks appear to exert an even greater influence on the nature and characteristics of help-seeking pathways of Chinese people, particularly in relation to help-seeking for mental health concerns (Kramer et al., 2002; Pearson, 1993). In a society with a collectivist and a familial orientation, parents and elders in the family still hold strong beliefs that they are responsible for taking care of their offspring, disabled or not (Young, 1996). Moreover, the decision to seek help does not rest with the individuals (i.e., young and/or disabled) but incorporates the views of different members in a family or close relatives and friends. Therefore, how people in a close informal network perceive the symptoms and the mental health services greatly affect the course and nature of the help-seeking pathways to be taken by the Chinese families.

Due to strong stigmatization of mental illness, individuals with a mental illness and their family members may be hesitant to approach personnel of formal psychiatric services for help ( Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000). They are reluctant to disclose their problems to others because of a fear of social rejection, social distancing, and hostility. In the initial stage of the development of a mental illness, these individuals may ignore the presence of the symptoms and ascribe these symptoms to causes other than mental illness. Others may try to manage the symptoms for as long as they can cope. Consequently, they may not venture out to seek help for their mental health problems. While psychiatric stigma exists in many cultures (Jorm, 2002), mental illness is certainly stigmatizing in the Asian cultures (Kramer et al., 2002).

In Hong Kong, studies conducted by the HKCSS and MHAHK have revealed that many Hong Kong Chinese people harbor a strong stigma about mental illness (HKCSS and MHAHK, 1996), and it is not uncommon for Chinese people to feel ashamed and fearful of having a relative with a mental illness. Consequently, there is a strong denial and concealment of mental illness in Chinese families. Indeed, studies have suggested that Chinese people with a mental illness often experience a much longer delay in help-seeking than other ethnic groups, and the duration of untreated psychosis can be as long as 1 to 2 years (Ryder et al., 2000; Skeate et al., 2002).

In the literature, the ability to recognize a mental illness is called Mental Health Literacy. This phrase refers to knowledge and beliefs about mental disorders which aid their recognition, management, or prevention (Jorm, 2000). Inherent in this concept is the assumption that individuals who have a higher level of mental health literacy will be more willing to seek professional help for themselves or for people they know who may be suffering from a mental health problem. Several studies have found that people who did not have sufficient knowledge of mental illness were unable to recognize the symptoms of a mental disorder (Jorm, Kitchener, Kanowski, & Kelly, 2007). As a result, they did not adequately communicate information to others or might view the symptoms as trivial (McGorry & Jackson, 1999). Moreover, this lack of knowledge might lengthen the duration of an untreated mental health condition (Drake, Haley, Akhtar, & Lewis, 2000).

In Chinese communities, studies have found that Chinese people had much lower percentages of mental health literacy in comparison with other cultural groups in overseas studies (Wong, He, Poon, & Lam, 2012; Wong, Lam, & Poon, 2010). For examples, when comparing with the percentage found in an Australian general population sample (i.e., about 64.20%), far fewer Chinese people in Shanghai (8.32%), Hong Kong (18.43%), and Australia (15.5%) could correctly identify the condition described in the vignette as a case of acute schizophrenia. Similarly, in comparison with the percentages found in the Australian and Canadian samples (67% and 75.6%, respectively), far fewer Chinese people in Shanghai (12.3%), Hong Kong (13.9%), and Australia (14%) recognized the vignette as one of depression. In the above cited studies, it is also found that there were a large number of Chinese people who did not have much understanding of the medical treatments for people with mental illness (e.g., drugs and hospitalization). In addition, there was a strong tendency for some Chinese people to seek traditional medical and social treatments for their mental health problems. Finally, there was some confusion about the roles and functions of various professionals (e.g., psychiatrist and psychologist). Given this information, proper knowledge concerning the above-mentioned issues will help Chinese people to make informed choices regarding what, who, and why they choose a certain psychiatric intervention in a promptly manner.

Mental Health First Aid Program

Mental Health First Aid (MHFA) program is originated from Australia and is a public education program aiming to help the general public to provide initial help to people with a mental health problem. In Hong Kong, MHAHK has sponsored a Chinese translation and has introduced it to local Chinese community since 2004. MHFA is a 12-hour program run by certified instructors. The contents of MHFA training can be divided into three sections (MHAHK, 2013). The first section defines mental health and presents information relating to the epidemiology and impact of mental illness in the Hong Kong community. It also documents the spectrum of interventions, from prevention and early intervention to treatment and supports. Common cultural and societal myths and misunderstandings such as “people who have mental illnesses are dangerous” and “people who have mental illness should be segregated” are discussed, as well as the impact of stigma and discrimination on the help-seeking behaviors of people with mental health problems. The first section concludes with a step-by-step action plan called ALGREE (A --“Approach, Assess, and Assist” the person with any crisis; L --“Listen” non-judgmentally; G --“Give” support and information; E --“Encourage” the person to get appropriate professional help; and E --“Encourage” other supports), which enables participants to remember the plan of action to assist a person who is experiencing a mental health crisis or who may be developing mental health problems.

The second section contains different types of mental health problems: depression, anxiety, psychosis, and substance Misuse. Under each category, information is provided about the types, risk factors, interventions, importance of early intervention, crises associated with the disorder, and helpful resources. The action plan is applied to each category, specifying the actions that need to be taken. In addition, culturally and traditionally endorsed treatment methods pertaining to each of the above-mentioned diagnoses are also discussed and clarified. For example, “Can qiqong and nutritional supplements help to cure depression?” Information pertaining to “what to do” and “what not to do” is provided as well. The third section covers first aid for mental health crises, such as suicidal thoughts and behaviors, nonsuicidal self-injury, severe psychotic states, acute effects of drug and alcohol misuse, and aggressive behaviors. Since professional assistance is not always immediately forthcoming in an emergency, it is necessary for the MHFA providers to have some knowledge about how to preserve life, prevent further harm, promote recovery, and provide comfort.

Effectiveness of MHFA Program

There are 26 published studies relating to MHFA (2015). One of which is a meta-analysis which aimed to estimate the effects and potential of MHFA as a public mental health awareness-increasing strategy (Hadlaczky, Hökby, Mkrtchian, Carli, & Wasserman, 2014). Fifteen relevant articles were identified through this systematic analysis. Results suggested that participants of MHFA showed an improvement in concordance with health professionals about treatments, increase in helping behaviors, greater confidence in providing help to others, reduction in social stigma, and an increase in actual help rendered to people with a mental health problem. With the exception of a few study conducted in the United Kingdom, United States, Sweden, and Canada, the majority of the research were done in Australia using Australian subjects. Two studies evaluated MHFA program for Vietnamese and Chinese Australians, and the results showed that improvement in mental health literacy was found in these ethnic and cultural groups in Australia (A. Y. K. Lam, Jorm, & Wong, 2010; Minas, Colucci, & Jorm, 2009). However, no data are available to support the effectiveness of MHFA in other cultural groups or in different political and sociocultural contexts.

On the whole, the 26 studies were beset with certain methodological and theoretical limitations. First, some of these studies adopted a one group pretest–posttest design (i.e., without, a control or comparison group) making results “uninterpretable” (Heppner, Wampold, & Kivlighan, 2008). Additionally, they did not have a follow-up test to ascertain the longer term effects of the MHFA program intervention. Second, these studies used and translated the questionnaire constructed by Jorm and Kitchener, without taking into consideration of the cultural preference for certain formal and informal professional inputs, as well as modern and traditional treatment and intervention methods, such as those among Chinese and Vietnamese people. A culturally attuned questionnaire may provide more information about the nature and changes in mental health literacy among the specific cultural groups. Finally, theoretically, the results of these studies may not be transferrable to Chinese and Vietnamese in other parts of the world because of political and sociocultural contextual differences. The present evaluation study set out to evaluate the effectiveness of MHFA in improving the participants’ mental health literacy, reducing stigma of mental illness, and increasing their confidence in helping people with potential mental health problems. This study had the following hypotheses. When comparing to the control group, the participants in the experimental group would have:
increased knowledge of mental disorders (i.e., [a] recognition of depression and schizophrenia and [b] agreement with health professionals about treatments for people with depression and schizophrenia upon the completion of MHFA and at 6-month follow-up;

less social stigma (i.e., [a] perceived dangerousness, [b] perceived dependency, and [c] preferred social distance) toward a person with mental disorders upon the completion of MHFA and at 6-month follow-up; and

more confidence in providing help to a person with mental health problem upon the completion of MHFA and at 6-month follow-up.

Method

Participants

This study adopted a quasi-experimental design with pretest, posttest, and follow-up. Given the anticipated effect size of 0.5, a desired statistical power level of 0.8 and α level of .05, it was estimated that a minimum sample size of 128 was needed for a two-group statistical analysis (Howell, 2013). The selection criteria for the two groups included (a) general public aged 18 or above and (b) have the ability to understand Chinese.

For both experimental and comparison groups, the participants were the general public who were either interested in acquiring knowledge and basic skills in engaging with a person with potential/actual mental health problem or skills in managing their stress and/or health information. They were recruited by the staff of the MHAHK through its normal recruitment channels, such as internet, poster, newsletter, e-mail, and so on. The participants were required to sign a consent form before joining the MHFA course. The voluntary nature and the risks and benefits of joining the program were explained in the consent form. Randomization was not performed because many potential participants indicated that they were interested in either acquiring knowledge in MHFA or stress management or health information and did not want to participate in any research. This project was endorsed by the Ethics Committee of City University of Hong Kong.

The participants in the experimental group went through a 12-hour MHFA training conducted by a certified MHFA instructor who was a mental health professional and had undergone a 5-day instructor training in MHFA. The participants in the comparison group received educational programs on stress management and physical health enhancement. None of the contents overlapped with the MHFA program. All the MHFA courses and other seminars were conducted between June 2010 and May 2011.

There were 138 participants in the experimental group, of whom 68% were women and 30% were men. More than 70% of the sample in the experimental group fell into the age range of 18–45. Majority of them were born in Hong Kong, and more than half of the sample had received an undergraduate degree in the experimental group. About 56% and 34% of the sample were single and married, respectively. While more than 70% had full-time employment, 88% in the experimental group had income below HKD$30,000. On the contrary, the comparison group consisted of 139 participants. With respect to gender, 70% were women and 29% were men. More than 70% of the sample in the control group fell into the age range of 18–45. Majority of them were born in Hong Kong, and more than half of the sample had received an undergraduate degree in both the experimental and comparison groups. About 54% and 38% of the sample were single and married, respectively. While more than 50% had full-time employment, 82% in both groups had income below HKD$30,000. Chi-square tests were conducted to explore the demographic differences between the experimental and comparison groups. Results showed no significant differences between the two groups (all Ps > .05). Generally speaking, the profiles of the two groups were comparable.

Measures

Mental Health Literacy Scale

The Chinese version of the scale, which was translated and adapted from Jorm (2000) for their study of mental health literacy among the Australian samples, was used in this study (Wong, 2010). The questionnaire is based on two vignettes: major depression and schizophrenia, which are written to satisfy the diagnostic criteria according to Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) and International Classification of Diseases, Tenth Revision. After reading the vignettes, respondents are asked a series of questions to assess their recognition of the disorders; their awareness of mental illness; and the beliefs about the helpfulness or harmfulness of different professions, medications, and treatment methods. These questions include “Do you think the person need help or not?” (Yes/No) and “What mental health issue do you think the person is having?” The rest of the questions involve the respondent’s knowledge and views about the various professionals who can help the person and a range of appropriate treatments. Participants are asked to rate on each type of (a) professionals, (b) medications, and (c) treatments as “Helpful”, “Harmful,” or “Not Sure” in relation to the mental health issue faced by the person in the vignette. Additional cultural items are included on the basis of literature review and our clinical experience in working with Chinese people. Examples of these items are “Chinese medical doctor,” “Chinese traditional healer,” “Chinese herbal medicine,” “taking Chinese nutritional foods/supplements,” “qiqong,” “changing fungshui,” and “traditional prayer” were included.

The scoring method for professional consensus followed the suggestion provided by Jorm (2000). Specifically, for the depression vignette, a rating of general practitioner, psychiatrist, clinical psychologist, antidepressant, counseling, or cognitive behavior therapy as “helpful” would receive 1 point for each correct answer. Similarly, for the schizophrenia vignette, a rating of general practitioner, psychiatrist, clinical psychologist, antipsychotics, and admission to a ward as helpful would receive 1 point for each correct answer. Thus, the score on professional consensus ranges from 0 to 6 for the depression vignette and 0–5 for the schizophrenia vignette.

Stigmatization toward mental illness

The measurement of stigmatization consists of two domains: (a) Personal Attributes Scale (Angermeyer & Matschinger, 2003) and (b) Social Distance (Link, Phelan, Bresnahan, Stueve, & Pescosolido, 1999). The Personal Attribute Scale is comprised of 8 items with two kinds of stereotype of mental illness: dangerousness and dependency. Respondents are asked to rate on a 5-point Likert-type scale, ranging from definitely agree (1) to definitely not agree (5), on dangerousness and dependency in relation to depression or schizophrenia. Items are reversely scored, with lower score representing higher endorsement of these personal attributes. Mean score are calculated for each kind of personal attributes. The reliability coefficients for the Personal Attribute Scale in the present study ranged from .69 to .98, which showed good internal consistency. Finally, the Social Distance Scale consists of 5 items representing five types of interpersonal relationship one is willing to have with a person with mental illness. These include being neighborhood, spending a weekend, becoming a friend, being a workmate, and marrying into family. Each question is rated on a 4-point Likert-type scale (1 = definitely will, 2 = probably will, 3 = probably will not, and 4 = definitely will not). The higher the mean score, the greater the preference it is for social distance. In this study, the reliability coefficients for the social distance scale ranged from .81 to .98, demonstrating the internal consistency of the distributions was satisfactory.

Procedure

Figure 1 presents a flow diagram of participants through each stage of the study. For both experimental and comparison groups, participants were recruited by the staff of the MHAHK through its normal recruitment channels, such as internet, poster, newsletter, e-mail, and so on. The participants were required to sign a consent form before joining the MHFA course. The voluntary nature and the risks and benefits of joining the program were explained in the consent form. All the MHFA courses and other seminars were conducted between June 2010 and May 2011.

Figure 1.
Flow diagram of the stages of the study.

Statistical Analyses

Data analyses were performed on an intention-to-treat basis, with the missing data for each outcome measure imputed using “last observation carried forward.” Differences in each outcome measure between the two groups were examined using χ² analyses for categorical variables and analyses of variance (ANOVAs) for continuous variables. A series of 2 × 3 mixed design ANOVAs were performed to examine the main and interaction effects of time and group on the outcome measures at pretest, posttest, and follow-up (Howell, 2013). Post hoc pairwise comparisons using Bonferroni test were used to examine the level of significance between pretest and posttest, and pretest and follow-up test in the outcome measures in the experimental group (Howell, 2013). Finally, Cohen’s d was used to measure the magnitude of change between pretest and posttest, and pretest and follow-up in the experimental group only (Cohen, 1988).

Results

Differences in each demographic and outcome measure between the experimental and control groups at pretest were examined using χ² analyses for categorical variables and ANOVAs for continuous variables. Results suggest a lack of significance in these variables, indicating that the two groups were comparable and shared similar characteristics at pretest (Table 1).

Table 1.
Demographic Characteristics of the Participants in the Two Groups.

Experimental Comparison χ²

N = 138, % N = 139, %

Gender Male 29.70 28.80 .90

Female 67.40 69.80

Missing 2.90 1.40

Age 18–25 27.50 40.30 .15

26–35 25.40 18.00

36–45 17.40 13.70

46–55 22.50 18. 70

56–65 4.30 6.50

Missing 2.90 2.90

Years in Hong Kong <7 .70 2.20 .48

≥7 24.60 20.90

Born in Hong Kong 72.50 74.80

Missing 2.20 2.20

Education F3 or below 1.40 2.20 .45

F3–F5 25.40 25.90

Preparatory 5.80 6.50

Undergraduate 52.20 57.60

Postgraduate 13.00 6.50

Missing 2.20 1.40

Marital status Married 34.10 38.10 .45

Separated/divorced 6.50 2.90

Single 55.80 54.00

Co-habit .70 1.40

Missing 2.90 3.60

Employment Full time 71.00 52.50 .06

Part time 9.40 16.50

Unemployed 10.10 10.10

Housewife 2.90 6.50

Retired 2.90 5.00

Missing 3.60 9.40

Monthly income (individual) <10,000 34.10 46.00 .08

10,001–20,000 40.60 25.20

20,001–30,000 13.00 10.80

30,001–40,000 3.60 4.30

>40,001 2.20 3.60

Missing 6.50 10.10

Reason for joining the program Interest 63.80 61.90 .80

Self-enrichment 68.80 69.80 .90

Work need 42.80 24.50 .07

Study-related 15.20 12.20 .49

Relative of patients with mental illness 17.40 12.20 .24

Friend of patients with mental illness 13.00 9.40 .35

The means, standard deviations, and intervention effects of the outcome measures are presented in Tables 2 and 3. A significant overall time effect was observed for most of the outcome measures. Significant positive changes in the recognition of depression (F = 20.71, p < .00) and schizophrenia (F = 6.74, p < .00); professional consensus on depression (F = 22.79, p < .00) and schizophrenia (F = 20.99, p < .00); social distance concerning depression (F = 11.48, p < .00) and schizophrenia (F = 5.73, p < .00); and confidence in offering help to others (F = 9.78, p < .05) were found in the participants across pretest, posttest, and follow-up test, except for dangerousness and dependency measures (Table 3).

Table 2.
Means and Standard Deviations for Pretest, Posttest, and Follow-Up Test by Outcome Measures.

Experimental Pretest Posttest Follow-Up

M (SD) M (SD) M (SD)

Depression

Recognition of disorder .30 (.46) .63 (.48) .63 (.48)

Professional consensus 4.51 (1.35) 5.49 (1.01) 5.20 (1.03)

Dangerousness 1.99 (.72) 2.13 (.99) 2.05 (.65)

Dependency 2.97 (1.01) 2.94 (.96) 3.05 (.90)

Social distance 1.80 (.66) 1.66 (.68) 1.65 (.59)

Schizophrenia

Recognition of disorder .33 (.47) .58 (.50) .50 (.50)

Professional consensus 3.63 (1.14) 4.43 (.94) 4.17 (.97)

Dangerousness 2.86 (1.03) 2.78 (.94) 2.98 (.91)

Dependency 3.13 (1.01) 2.99 (.98) 3.14 (.94)

Social distance 2.25 (.76) 2.02 (.73) 2.16 (.70)

Confidence to help 2.88 (.98) 3.07 (.86) 3.07 (.86)

Control

Depression

Recognition of disorder .30 (.46) .30 (.46) .31 (.46)

Professional consensus 4.49 (1.33) 4.49 (1.33) 4.51 (1.28)

Dangerousness 2.16 (.66) 2.16 (.66) 2.15 (.73)

Dependency 3.12 (.79) 3.12 (.79) 3.01 (.92)

Social distance 2.12 (.60) 2.12 (.60) 1.95 (.57)

Schizophrenia

Recognition of disorder .36 (.48) .36 (.48) .33 (.47)

Professional consensus 3.36 (1.21) 3.36 (1.21) 3.47 (1.22)

Dangerousness 3.14 (.91) 3.14 (.91) 3.31 (.97)

Dependency 3.23 (.91) 3.23 (.91) 3.36 (1.96)

Social distance 2.65 (.75) 2.65 (.75) 2.59 (.75)

Confidence to help 2.52 (.97) 2.52 (.97) 2.67 (1.10)

Table 3.
Time and Group Effects, Pairwise Comparison, and Effect Size of Outcome Measures.

Group Effects Time Effects Pairwise Comparison Effect Size (Pre–Post) Effect Size (Pre-Follow Up)

F p; M [95% CIs] F Pre–Post; p; M _Diff [95% CIs] Pre-Follow-up; p; M _Diff [95% CIs] Cohen’s d Cohen’s d

Depression

Recognition of disorder 24.95 <.01; .52 [.46, .58] 20.71 <.01; −.16 [−.22, −.11] <.01; −.17 [−.25, −.09] .63 .55

Professional consensus 23.02 <.01; 5.07 [4.90, 5.23] 22.79 <.01; −49 [−65, −.34] <.01; −.36 [−.56, −.15] .65 .48

Dangerousness 2.04 .16; 2.06 [1.96, 2.15] 1.09 .11; −.07 [−1.75, .03] .32; −.03 [−.12, .06] .14 .09

Dependency 1.20 .27; 3.04 [2.95, 3.12] .08 .73; .02 [−.08, .11] .40; .02 [−.10, .14] .03 .07

Social distance 32.75 <.01; 1.70 [1.61, 1.79] 11.48 <.01; .07 [.01, .12] <.01; .16 [.09, .23] .21 .23

Schizophrenia

Recognition of disorder 7.78 <.01; .41, [.37, .45] 6.74 <.01; −.12 [−.18, −.07] <.01; −.07 [−.14, −.01] .41 .26

Professional consensus 37.79 <.01; 4.08 [3.93, 4.24] 20.99 <.01; −.40 [−.53, −.28] <.01; −.33 [−.51, −.15] .66 .46

Dangerousness 1.98 .21; 2.87 [2.74, 3.00] 2.18 .32; .04 [−.04, .12] .15; −.14 [−.26, −.02] .08 .12

Dependency 2.90 .11; 3.06 [2.94, 3.23] 1.45 .12; .07 [.02, .16] .87; −.07 [−.26, .12] .14 .01

Social distance 36.08 <.01; 2.15, [2.04, 2.26] 5.73 <.01; .12 [.06, .17] .07; .08 [.01, .16] .38 .15

Confidence to help 14.39 <.01; 2.81, [2.71, 2.91] 9.78 <.05; −.18 [−.31, −.04] <.05; −.18 [−.31, −.04] .21 .20

Post hoc pairwise comparisons using Bonferroni test and Cohen’s d analyses revealed modest to moderate improvements in all major variables in the experimental group (i.e., Cohen’s d ranging from .20 to .499 for modest improvement and .50 to .799 for moderate improvement) between pretest and posttest and pretest and follow-up, except for dangerousness and dependency measures (Table 3).

Significant group effects were also found in most of the outcome measures. When compared to the control group, significant positive changes in the recognition of depression (F = 24.95, p < .00) and schizophrenia (F = 7.78, p < .00); professional consensus on depression (F = 23.02, p < .00) and schizophrenia (F = 37.79, p < .00); social distance concerning depression (F = 32.75, p < .00) and schizophrenia (F = 36.08, p < .00); and confidence in offering help to others (F = 14.39, p < .00) were found in the participants of the experimental group, except for dangerousness and dependency measures. Dangerousness measures for depression were (F = 2.04, p = .16) and schizophrenia (F = 1.98, p = .21) respectively, while dependency measures for depression and schizophrenia were (F = 1.20, p = .27) and (F = 2.90, p = .11), respectively.

To conclude, significant improvement was found in mental health literacy, stigma (i.e., indicated by social distance), and confidence in offering help, across times, among participants of the experimental group and between the participants of the experimental and control groups.

Discussion and Applications to Practice

In this study, one of the major objectives was to find out if MHFA programs would increase the recognition and knowledge of mental illness among participants in the MHFA programs. The increase in the knowledge of mental illness was indicated by the increases in the recognition of depression and schizophrenia and the beliefs about the helpfulness of professionals in helping people with depression and schizophrenia. Results suggest that the Hong Kong version of the MHFA programs was able to facilitate Hong Kong participants to build mental health knowledge, which is consistent with previous studies for both English-speaking (Kitchener & Jorm, 2002) and Chinese-speaking communities in Melbourne, Australia (A. Y. K. Lam et al., 2010). Specifically, MHFA programs enhanced Chinese participants’ ability to recognize depression or schizophrenia and increased their beliefs about the helpfulness of professionals for treatment. These positive effects carried forward 6 months postintervention. Given the estimates that 1.05 to 1.75 million Hong Kong people potentially suffer from a range of mental disorders in Hong Kong (Hospital Authority, 2010) and that only a small portion of these individuals seek and receive psychiatric and psychological treatments (S. Lee et al., 2007), our MHFA program can help some of these individuals and people around them to quickly recognize their potential mental health problems and to identify and approach appropriate mental health professionals in a timely manner. Incidentally, with the recent influx of Chinese migrants to countries such as Australia, Canada, United States, and United Kingdom, this culturally attuned MHFA can surely benefit Chinese people living in these countries. For example, China is now the top birthplace of Australians who were born outside of Australia, and Mandarin is the top language other than English spoken by Australians at home (ABS, 2012).

Positive changes in the knowledge of mental illness are not surprising because the contents of the MHFA programs were specifically designed to help participants recognize the major symptoms and risk factors of main mental disorders (i.e., depression, anxiety, psychosis, and substance abuse). It also clearly spelt out the roles of different professionals, including general physician, clinical psychologist, counselor, social worker, and psychiatrist, in the treatment of mental disorder, which helped participants understand what these professionals could do for people with a mental disorder. In addition, our MHFA programs introduced the causes and Western and Chinese treatment approaches for the main mental disorders described earlier. Specifically, our MHFA programs focused on Western approaches and their effectiveness for the treatment of various mental disorders and brought forth for discussion the possible positive and negative effects of various Chinese traditional approaches such as traditional healer and changing fungshui in the treatment of mental illness. Indeed, the introduction of the Chinese perspectives of the causation and treatment of a mental disorder aroused a great deal of discussion among participants in our MHFA program.

This study reveals that our MHFA programs were able to reduce the perceived social distance among the participants in the MHFA programs. Generally speaking, imparting mental health knowledge might have helped participants break down the myths of and normalize mental illness, which then decreased the participants’ perceived social distance from people with mental health problems.

However, our programs did not result in the significant reduction of perceived dangerousness and dependency among the participants in the MHFA groups across the three time periods and between the two groups of participants. This lack of significance may be explained by the cultural stigma of mental illness that is deeply entrenched in the Chinese culture. According to C. S. Lam et al. (2010), mental illness is described as “dian” and “kuang” which means insane and crazy. Other lay beliefs include weak character and punishment for one’s transgression in this life or in the previous one (Y. T. Lee & Wang, 2003). Regardless of the above-mentioned descriptions, people with a mental illness in Chinese culture are generally perceived as dangerous, unpredictable, and uncontrollable (C. S. Lam et al., 2010). It is therefore not uncommon for Chinese people to feel ashamed and fearful of having a relative with a mental illness. Given this strong and deeply entrenched Chinese cultural stigma, it should not be surprising to discover that changes in the perceived dangerousness and dependency did not make much improvement. Hence, much more effort with longer-term strategies is needed to possibly produce significant changes in stigma of mental illness in Chinese people.

Consistent with the previous findings, our MHFA programs appear to be effective in increasing Chinese participants’ confidence in offering help to people with mental health problems. One way of explaining this is that, the participants in the MHFA groups had gained an increase in the knowledge of mental illness and therefore would feel more confidence in rendering help to people with a mental illness. Such a positive increase in confidence might have also been boosted by the increase in basic engagement skills—(ALGEE: A—“Approach, Assess, and Assist” the person with any crisis; L—“Listen” non-judgmentally; G—“Give” support and information; E—“Encourage” the person to get appropriate professional help; and E—“Encourage” other supports)—that were repeatedly taught to and role played among the participants throughout the 12 hours of MHFA training. However, a positive change in the confidence in helping behaviors does not necessarily equate to changes in actual helping behaviors rendering to a person with a mental illness. Future research needs to obtain information pertaining to actual helping behaviors performed by the participants in an MHFA program.

In this study, the findings of our culturally attuned MHFA programs with its standardized manual appear to lend some support to the effectiveness of the program in increasing Chinese participants’ knowledge of mental illness, both in terms of the recognition of mental disorder and the beliefs about the helpfulness of professionals in helping people with depression and schizophrenia. Given the effectiveness of our Chinese version of the MHFA program, it is recommended that this evidence-based MHFA programs can be adopted as one of the strategies in promoting better mental health among Chinese communities in different countries. Funding should be given to health and social service organizations for implementing MHFA programs in these communities.

This study also reveals that our MHFA program could not fully address the deep-rooted cultural stigma of mental illness held by the Chinese people. It is recommended that an additional and separate program should be designed and implemented to tackle the issue relating to psychiatric stigma among Chinese people in Hong Kong and elsewhere. The contents may include Chinese views on psychiatric stigma, social and psychological influences in psychiatric stigma, and simulated and real life activities that increase the awareness of stigma and encourage contact between people with mental illness and the general public. Studies found that increased contact has resulted in a reduction in psychiatric stigma among the participants (Couture & Penn, 2003).

The findings of this study should be treated cautiously, due to its limitations. To begin with, this was not a randomized control study, and the subjects were recruited through convenience sampling. Therefore, the sample might be biased and might not be representative of the general population of Chinese in Hong Kong and elsewhere. Moreover, our study had adopted a 6-month follow-up test to measure the maintenance effect of mental health aid training on various outcome variables in the study. In addition, it only measured the “perceived” confidence of offering help to people with suspected mental health concerns. Further study may benefit from adopting a 1-year follow-up test period and measuring the “actual” help offered by the participants of the MHFA program to people with mental health concerns.

In conclusion, this study lends some support to the effectiveness of MHFA training in improving recognition of mental disorders, reducing negative stigmatizing attitudes, changing beliefs about the helpfulness of treatment, and in the perceived confidence in offering help to people with suspected mental health concerns among Chinese participants in Hong Kong. The evidence from this study, together with the accumulated evidences of the benefits of MHFA training in other target groups such as the ethnic minorities and the adolescents, suggests that this approach can be tried in different Chinese population groups in Hong Kong and elsewhere. Evaluations of these programs should also be carried out to ascertain their effectiveness in promoting better mental health among the targeted populations.

		Experimental	Comparison	χ²
Gender	Male	29.70	28.80	.90
Female	67.40	69.80
Missing	2.90	1.40
Age	18–25	27.50	40.30	.15
26–35	25.40	18.00
36–45	17.40	13.70
46–55	22.50	18. 70
56–65	4.30	6.50
Missing	2.90	2.90
Years in Hong Kong	<7	.70	2.20	.48
≥7	24.60	20.90
Born in Hong Kong	72.50	74.80
Missing	2.20	2.20
Education	F3 or below	1.40	2.20	.45
F3–F5	25.40	25.90
Preparatory	5.80	6.50
Undergraduate	52.20	57.60
Postgraduate	13.00	6.50
Missing	2.20	1.40
Marital status	Married	34.10	38.10	.45
Separated/divorced	6.50	2.90
Single	55.80	54.00
Co-habit	.70	1.40
Missing	2.90	3.60
Employment	Full time	71.00	52.50	.06
Part time	9.40	16.50
Unemployed	10.10	10.10
Housewife	2.90	6.50
Retired	2.90	5.00
Missing	3.60	9.40
Monthly income (individual)	<10,000	34.10	46.00	.08
10,001–20,000	40.60	25.20
20,001–30,000	13.00	10.80
30,001–40,000	3.60	4.30
>40,001	2.20	3.60
Missing	6.50	10.10
Reason for joining the program	Interest	63.80	61.90	.80
Self-enrichment	68.80	69.80	.90
Work need	42.80	24.50	.07
Study-related	15.20	12.20	.49
Relative of patients with mental illness	17.40	12.20	.24
Friend of patients with mental illness	13.00	9.40	.35

Experimental	Pretest	Posttest	Follow-Up
Depression
Recognition of disorder	.30 (.46)	.63 (.48)	.63 (.48)
Professional consensus	4.51 (1.35)	5.49 (1.01)	5.20 (1.03)
Dangerousness	1.99 (.72)	2.13 (.99)	2.05 (.65)
Dependency	2.97 (1.01)	2.94 (.96)	3.05 (.90)
Social distance	1.80 (.66)	1.66 (.68)	1.65 (.59)
Schizophrenia
Recognition of disorder	.33 (.47)	.58 (.50)	.50 (.50)
Professional consensus	3.63 (1.14)	4.43 (.94)	4.17 (.97)
Dangerousness	2.86 (1.03)	2.78 (.94)	2.98 (.91)
Dependency	3.13 (1.01)	2.99 (.98)	3.14 (.94)
Social distance	2.25 (.76)	2.02 (.73)	2.16 (.70)
Confidence to help	2.88 (.98)	3.07 (.86)	3.07 (.86)
Control
Depression
Recognition of disorder	.30 (.46)	.30 (.46)	.31 (.46)
Professional consensus	4.49 (1.33)	4.49 (1.33)	4.51 (1.28)
Dangerousness	2.16 (.66)	2.16 (.66)	2.15 (.73)
Dependency	3.12 (.79)	3.12 (.79)	3.01 (.92)
Social distance	2.12 (.60)	2.12 (.60)	1.95 (.57)
Schizophrenia
Recognition of disorder	.36 (.48)	.36 (.48)	.33 (.47)
Professional consensus	3.36 (1.21)	3.36 (1.21)	3.47 (1.22)
Dangerousness	3.14 (.91)	3.14 (.91)	3.31 (.97)
Dependency	3.23 (.91)	3.23 (.91)	3.36 (1.96)
Social distance	2.65 (.75)	2.65 (.75)	2.59 (.75)
Confidence to help	2.52 (.97)	2.52 (.97)	2.67 (1.10)

	Group Effects	Time Effects	Pairwise Comparison	Effect Size (Pre–Post)	Effect Size (Pre-Follow Up)
Depression
Recognition of disorder	24.95	<.01; .52 [.46, .58]	20.71	<.01; −.16 [−.22, −.11]	<.01; −.17 [−.25, −.09]	.63	.55
Professional consensus	23.02	<.01; 5.07 [4.90, 5.23]	22.79	<.01; −49 [−65, −.34]	<.01; −.36 [−.56, −.15]	.65	.48
Dangerousness	2.04	.16; 2.06 [1.96, 2.15]	1.09	.11; −.07 [−1.75, .03]	.32; −.03 [−.12, .06]	.14	.09
Dependency	1.20	.27; 3.04 [2.95, 3.12]	.08	.73; .02 [−.08, .11]	.40; .02 [−.10, .14]	.03	.07
Social distance	32.75	<.01; 1.70 [1.61, 1.79]	11.48	<.01; .07 [.01, .12]	<.01; .16 [.09, .23]	.21	.23
Schizophrenia
Recognition of disorder	7.78	<.01; .41, [.37, .45]	6.74	<.01; −.12 [−.18, −.07]	<.01; −.07 [−.14, −.01]	.41	.26
Professional consensus	37.79	<.01; 4.08 [3.93, 4.24]	20.99	<.01; −.40 [−.53, −.28]	<.01; −.33 [−.51, −.15]	.66	.46
Dangerousness	1.98	.21; 2.87 [2.74, 3.00]	2.18	.32; .04 [−.04, .12]	.15; −.14 [−.26, −.02]	.08	.12
Dependency	2.90	.11; 3.06 [2.94, 3.23]	1.45	.12; .07 [.02, .16]	.87; −.07 [−.26, .12]	.14	.01
Social distance	36.08	<.01; 2.15, [2.04, 2.26]	5.73	<.01; .12 [.06, .17]	.07; .08 [.01, .16]	.38	.15
Confidence to help	14.39	<.01; 2.81, [2.71, 2.91]	9.78	<.05; −.18 [−.31, −.04]	<.05; −.18 [−.31, −.04]	.21	.20

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The authors alone are responsible for the content and writing of the paper.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The study was commissioned by The Mental Health Association of Hong Kong.

References

ABS. (2012). Births, Country of birth, Australia, 2012. Retrieved March 15, 2015, from http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/3301.02012

Addington

Mastrigt

Hutchinson

Addington

(2002). Pathways to care: Help seeking behavior in first episode psychosis. Acta Psychiatrica Scandinavica, 106, 358–364.

Angermeyer

M. C.

Matschinger

(2003). The stigma of mental illness: Effects of labelling on public attitudes towards people with mental disorder. Acta Psychiatrica Scandinavica, 108, 304–309.

Black

Peter

Rui

Milliken

Whitehorn

Kopala

L. C.

(2001). Duration of untreated psychosis predicts treatment outcome in an early psychosis program. Schizophrenia Research, 47, 215–222.

Burnett

Mallett

Bhugra

Hutchisn

Der

Leff

(1999). The first contact of patients with schizophrenia with psychiatrist services: Social factors and pathways to care in a multi-ethnic population. Psychological Medicine, 29, 475–483.

Cohen

(1988). Statistical power analysis for the behavioral sciences. (p. 567). New Jersey, NJ: Lawerence Earlbaum Associates.

Couture

Penn

(2003). Interpersonal contact and the stigma of mental illness: A review of the literature. Journal of Mental Health, 12, 291–305. doi:10.1080/09638231000118276

Crisp

A. H.

Gelder

M. G.

Rix

Meltzer

H. I.

Rowlands

O. J.

(2000). Stigmatisation of people with mental illnesses. The British Journal of Psychiatry, 177, 4–7.

Drake

R. J.

Haley

C. J.

Akhtar

Lewis

S. W.

(2000). Causes and consequences of duration of untreated psychosis in schizophrenia. The British Journal of Psychiatry, 177, 511–515.

10.

Edward

McGorry

P. D.

(2002). Implementing early intervention in Psychosis: A guide to establishing early psychosis services. London, England: Martin Dunitz.

11.

Hadlaczky

Hökby

Mkrtchian

Carli

Wasserman

(2014). Mental Health First Aid is an effective public health intervention for improving knowledge, attitudes, and behavior: A meta-analysis. International Review of Psychiatry, 4, 467–475. doi:10.3109/09540261.2014.924910

12.

Heppner

Wampold

Kivlighan

(2008). Research design in counseling (5th ed.). Belmont, CA: Thomson Brooks/Cole

13.

Hong Kong Council of Social Services and Mental Health Association of Hong Kong. (1996). Public attitudes towards mental health patients in Hong Kong: A follow-up study over two years. Hong Kong, China: Hong Kong Council of Social Service.

14.

Hospital Authority. (2010). Hospital authority mental health service plan for adults 2010-2015. Hong Kong, China: Hospital Authority.

15.

Howell

(2013). Statistical methods for psychology (8th ed.). Belmont, CA: Wadsworth Publishing.

16.

Jorm

A. F.

(2000). Mental health literacy: Public knowledge and beliefs about mental disorder. The British Journal of Psychiatry, 177, 396–401.

17.

Jorm

A. F.

Kitchener

B. A.

Kanowski

L. G.

Kelly

C. M.

(2007). Mental health first aid training for members of the public. International Journal of Clinical and Health Psychology, 7, 141–151.

18.

Kitchener

B. A.

Jorm

A. F.

(2002). Mental health first aid manual. Melbourne, Australia: Orygen Research Centre. doi:10.1186/1471-244X-2-10

19.

Kramer

E. J.

Kwong

Lee

Chung

(2002). Cultural factor influencing the mental health of Asian Americans. Western Journal of Medicine, 176, 227–231.

20.

Lam

A. Y. K.

Jorm

A. F

Wong

F. K. D.

(2010). Mental health first aid training for the Chinese community in Melbourne, Australia: Effects on knowledge about the attitudes toward people with mental illness. International Journal of Mental Health Systems 4, 18. doi:10.1186/1752-4458-4-18

21.

Lam

C. S.

Tsang

H. W. H.

Corrigan

P. W.

Lee

Y. T.

Angell

Shi

… Larson

J. E.

(2010). Chinese lay theory and mental illness stigma: Implications for research and practices. Journal of Rehabilitation, 76, 35–40.

22.

Lee

Tsang

Kwok

(2007). Twelve-month prevalence, correlates, and treatment preference of adults with DSM-IV major depressive episode in Hong Kong. Journal of Affective Disorders, 98, 129–136. doi:10.1016/j.jad.2006.07.009

23.

Lee

Y. T.

Wang

D. Y.

(2003). Aboriginal people in Taiwan continent, China and the Americas: Ethnic inquiry into common root and ancestral connection. In Li

X. B.

Zhang

(Eds.), Taiwan in the twenty-first century (pp. 63–82). Lanham, MD: University Press of America.

24.

Link

B. G.

Phelan

J. C.

Bresnahan

Stueve

Pescosolido

B. A.

(1999). Public conceptions of mental illness: Labels, causes, dangerousness and social distance. American Journal of Public Health, 89, 1328–1333.

25.

McGorry

P. D.

Jackson

H. J.

(1999). The recognition and management of early psychosis: A preventive approach. New York, NY: Cambridge University Press.

26.

Mental Health Association of Hong Kong. (2013). Mental health first aid. Hong Kong: Mental Health Association of Hong Kong. Retrieved from January 5, 2015, http://www.mhfa.org.hk

27.

Mental Health First Aid. (2015). Research: Current project. Retrieved from January 10, 2015, https://mhfa.com.au

28.

Minas

Colucci

Jorm

A. F.

(2009). Evaluation of mental health first aid training with members of the Vietnamese community in Melbourne, Australia. International Journal of Mental Health Systems 3, 19. doi:10.1186/1752-4458-3-19

29.

Pearson

(1993). Families in China: An undervalued resource for mental health? Journal of Family Therapy, 15, 163–185. doi:10.1111/j.1467-6427.1993.00752.x

30.

Ryder

A. G.

Bean

Dion

K. L.

(2000). Caregiver responses to symptoms of first-onset psychosis: A comparison study of Chinese and Euro-Canadian families. Transcultural Psychiatry, 37, 225–235. doi:10.1177/136346150003700207

31.

Skeate

Jackson

Birchwood

Jones

(2002). Duration of untreated psychosis and pathways to care in first-episode psychosis: Investigation of help-seeking behavior in primary care. The British Journal of Psychiatry, 181, 73–77.

32.

Wong

F. K. D.

Lam

Y. K. A.

Poon

(2010). Depression literacy among Australians of Chinese-speaking background in Melbourne, Australia. BMC Psychiatry, 10, 7. doi:10.1186/1471-244X-10-7

33.

Wong

F. K. D.

X. S.

Poon

Lam

Y. K. A.

(2012). Depression literacy among Chinese in Shanghai, China: A comparison with Chinese-speaking Australians in Melbourne and Chinese in Hong Kong. Social Psychiatry and Psychiatric Epidemiology, 47, 1235–1242. doi:10.1007/s00127-011-0430-4

34.

Wong

F. K. D.

J. C. M.

(2014). Cultural influence on Shanghai Chinese’s help seeking for mental health problems: Implications for social work practice. British Journal of Social Work, 44, 868–885. doi:10.1093/bjsw/bcs180

35.

Young

K. P. H.

(1996). Social work with families and children. In Chi

Cheung

S. K.

(Eds.), Social work in Hong Kong (pp. 11–23). Hong Kong: Hong Kong Social Workers Association.

		Experimental	Comparison	χ²
		N = 138, %	N = 139, %	χ²
Gender	Male	29.70	28.80	.90
	Female	67.40	69.80
	Missing	2.90	1.40
Age	18–25	27.50	40.30	.15
	26–35	25.40	18.00
	36–45	17.40	13.70
	46–55	22.50	18. 70
	56–65	4.30	6.50
	Missing	2.90	2.90
Years in Hong Kong	<7	.70	2.20	.48
	≥7	24.60	20.90
	Born in Hong Kong	72.50	74.80
	Missing	2.20	2.20
Education	F3 or below	1.40	2.20	.45
	F3–F5	25.40	25.90
	Preparatory	5.80	6.50
	Undergraduate	52.20	57.60
	Postgraduate	13.00	6.50
	Missing	2.20	1.40
Marital status	Married	34.10	38.10	.45
	Separated/divorced	6.50	2.90
	Single	55.80	54.00
	Co-habit	.70	1.40
	Missing	2.90	3.60
Employment	Full time	71.00	52.50	.06
	Part time	9.40	16.50
	Unemployed	10.10	10.10
	Housewife	2.90	6.50
	Retired	2.90	5.00
	Missing	3.60	9.40
Monthly income (individual)	<10,000	34.10	46.00	.08
	10,001–20,000	40.60	25.20
	20,001–30,000	13.00	10.80
	30,001–40,000	3.60	4.30
	>40,001	2.20	3.60
	Missing	6.50	10.10
Reason for joining the program	Interest	63.80	61.90	.80
	Self-enrichment	68.80	69.80	.90
	Work need	42.80	24.50	.07
	Study-related	15.20	12.20	.49
	Relative of patients with mental illness	17.40	12.20	.24
	Friend of patients with mental illness	13.00	9.40	.35

Experimental	Pretest	Posttest	Follow-Up
Experimental	M (SD)	M (SD)	M (SD)
Depression
Recognition of disorder	.30 (.46)	.63 (.48)	.63 (.48)
Professional consensus	4.51 (1.35)	5.49 (1.01)	5.20 (1.03)
Dangerousness	1.99 (.72)	2.13 (.99)	2.05 (.65)
Dependency	2.97 (1.01)	2.94 (.96)	3.05 (.90)
Social distance	1.80 (.66)	1.66 (.68)	1.65 (.59)
Schizophrenia
Recognition of disorder	.33 (.47)	.58 (.50)	.50 (.50)
Professional consensus	3.63 (1.14)	4.43 (.94)	4.17 (.97)
Dangerousness	2.86 (1.03)	2.78 (.94)	2.98 (.91)
Dependency	3.13 (1.01)	2.99 (.98)	3.14 (.94)
Social distance	2.25 (.76)	2.02 (.73)	2.16 (.70)
Confidence to help	2.88 (.98)	3.07 (.86)	3.07 (.86)
Control
Depression
Recognition of disorder	.30 (.46)	.30 (.46)	.31 (.46)
Professional consensus	4.49 (1.33)	4.49 (1.33)	4.51 (1.28)
Dangerousness	2.16 (.66)	2.16 (.66)	2.15 (.73)
Dependency	3.12 (.79)	3.12 (.79)	3.01 (.92)
Social distance	2.12 (.60)	2.12 (.60)	1.95 (.57)
Schizophrenia
Recognition of disorder	.36 (.48)	.36 (.48)	.33 (.47)
Professional consensus	3.36 (1.21)	3.36 (1.21)	3.47 (1.22)
Dangerousness	3.14 (.91)	3.14 (.91)	3.31 (.97)
Dependency	3.23 (.91)	3.23 (.91)	3.36 (1.96)
Social distance	2.65 (.75)	2.65 (.75)	2.59 (.75)
Confidence to help	2.52 (.97)	2.52 (.97)	2.67 (1.10)

	Group Effects		Time Effects	Pairwise Comparison		Effect Size (Pre–Post)	Effect Size (Pre-Follow Up)
	F	p; M [95% CIs]	F	Pre–Post; p; M _Diff [95% CIs]	Pre-Follow-up; p; M _Diff [95% CIs]	Cohen’s d	Cohen’s d
Depression
Recognition of disorder	24.95	<.01; .52 [.46, .58]	20.71	<.01; −.16 [−.22, −.11]	<.01; −.17 [−.25, −.09]	.63	.55
Professional consensus	23.02	<.01; 5.07 [4.90, 5.23]	22.79	<.01; −49 [−65, −.34]	<.01; −.36 [−.56, −.15]	.65	.48
Dangerousness	2.04	.16; 2.06 [1.96, 2.15]	1.09	.11; −.07 [−1.75, .03]	.32; −.03 [−.12, .06]	.14	.09
Dependency	1.20	.27; 3.04 [2.95, 3.12]	.08	.73; .02 [−.08, .11]	.40; .02 [−.10, .14]	.03	.07
Social distance	32.75	<.01; 1.70 [1.61, 1.79]	11.48	<.01; .07 [.01, .12]	<.01; .16 [.09, .23]	.21	.23
Schizophrenia
Recognition of disorder	7.78	<.01; .41, [.37, .45]	6.74	<.01; −.12 [−.18, −.07]	<.01; −.07 [−.14, −.01]	.41	.26
Professional consensus	37.79	<.01; 4.08 [3.93, 4.24]	20.99	<.01; −.40 [−.53, −.28]	<.01; −.33 [−.51, −.15]	.66	.46
Dangerousness	1.98	.21; 2.87 [2.74, 3.00]	2.18	.32; .04 [−.04, .12]	.15; −.14 [−.26, −.02]	.08	.12
Dependency	2.90	.11; 3.06 [2.94, 3.23]	1.45	.12; .07 [.02, .16]	.87; −.07 [−.26, .12]	.14	.01
Social distance	36.08	<.01; 2.15, [2.04, 2.26]	5.73	<.01; .12 [.06, .17]	.07; .08 [.01, .16]	.38	.15
Confidence to help	14.39	<.01; 2.81, [2.71, 2.91]	9.78	<.05; −.18 [−.31, −.04]	<.05; −.18 [−.31, −.04]	.21	.20