Does stigma towards mental illness decrease for youth 13-18 years old after
participating in school-based Youth Net Hamilton focus groups?
Authors and affiliations
Dr. Linda O’Mara
McMaster University
School of Nursing
Daina Mueller
City of Hamilton Public Health Services
Lorraine Grypstra
City of Hamilton Public Health Services
Dr. Gina Browne
McMaster University
System Link Research Unit
Dr. Noori Akhtar-Danesh
McMaster University
David Hoy
Hamilton Wentworth District School Board
Cheryl Vrkljan
Centre for Addiction and Mental Health
Date: Feb 6, 2009
Funded by:
The Provinical Centre of Excellence for Child and Youth Mental Health at CHEO (Award
Number RG-127)
For contact information
Dr. Linda O’Mara McMaster University [email protected] 905-525-9140 ext 22261
Mrs. Daina Mueller [email protected] 416-327-7320
Acknowledgements
We would like to acknowledge the contribution of the participants, parents, teachers,
community partners, and the Centre of Excellence for Child and Youth Mental Health for
helping us complete this study. In addition we would like to thank Maria Wong, data
analyst at the SLRU, McMaster University, Dr. Noori Akhtar Danesh, Associate
Professor, McMaster University and John Cullen, Research Assistant, Research Office
School of Nursing McMaster University for their help with the data analysis
Suggested citation of this report: Youth Net Focus Group Impact on Stigma Study
TABLE OF CONTENTS
EXECUTIVE SUMMARY .......................................................................................................................... 1
RATIONALE AND BACKGROUND ................................................................................................................. 1
RESEARCH QUESTIONS ............................................................................................................................... 1
METHODS ................................................................................................................................................... 2
FINDINGS .................................................................................................................................................... 2
IMPLICATIONS FOR PRACTICE AND POLICY ................................................................................................ 3
CONCLUSIONS ............................................................................................................................................ 3
1. INTRODUCTION .................................................................................................................................... 5
A. BACKGROUND INFORMATION / LITERATURE REVIEW ............................................................................ 5
B. PROJECT PARTNERS ................................................................................................................................ 8
C. RESEARCH QUESTIONS ......................................................................................................................... 10
2. METHODS.............................................................................................................................................. 11
A. STUDY DESIGN .....................................................................................................................................
B. INCLUSION/EXCLUSION CRITERIA ........................................................................................................
C. RECRUITMENT ......................................................................................................................................
D. PROCEDURE ..........................................................................................................................................
E. INTERVENTION......................................................................................................................................
F. MEASURES ............................................................................................................................................
G. DATA ANALYSIS...................................................................................................................................
H. ETHICS .................................................................................................................................................
I. CHALLENGES .........................................................................................................................................
11
11
11
11
12
12
14
14
14
3. RESULTS................................................................................................................................................ 15
A. STUDY PARTICIPATION RATE ...............................................................................................................
15
1. Study Dropouts................................................................................................................................ 15
2. Baseline Comparisons: Control and intervention groups............................................................... 15
B. RESEARCH QUESTION RESULTS ............................................................................................................ 16
C. QUALITATIVE REPORT ON FOCUS GROUPS ........................................................................................... 19
4. DISCUSSION.......................................................................................................................................... 20
1. Research Question 1 ....................................................................................................................... 21
2. Research Questions 2 and 3............................................................................................................ 22
3. Research Question 4 ....................................................................................................................... 23
4. Research Question 5 ....................................................................................................................... 25
B. LESSONS LEARNED ............................................................................................................................... 25
C. IMPLICATIONS FOR POLICY AND PRACTICE........................................................................................... 26
D. STUDY LIMITATIONS ............................................................................................................................ 28
E. NEXT STEPS .......................................................................................................................................... 28
5. CONCLUSIONS..................................................................................................................................... 29
6. KNOWLEDGE EXCHANGE PLAN ................................................................................................... 31
7. REFERENCE LIST .............................................................................................................................. 33
8. APPENDIX ............................................................................................................................................. 41
Executive Summary
Rationale and Background
Mental health is an important health issue for all individuals but particularly for youth as
most mental illnesses begin during adolescence and young adulthood and, many of
these affected youth do not tend to seek help for their mental health problems (Browne
et al., 2004). There are a number of reasons why this occurs; individuals may not want
to recognize they have a problem; they may not believe that treatment will work. They
also may be embarrassed or worried about what others will think of them, which can
lead to stigma (Corrigan & Penn, 1999). Negative beliefs about mental illness can affect
both those with and without mental health problems. Those with mental health problems
may not seek help; those without mental health problems may discriminate against
persons with mental illness. Therefore, programs that reduce these negative beliefs and
reduce mental illness stigma among youth are important to implement and evaluate as
they may increase the likelihood that youth who experience mental health problems will
seek support (Manion et al., 1997).
There are three common approaches used to reduce stigma: education; contact and
protest (Corrigan & Penn, 1999). Education seeks to provide facts about mental illness
in order to get rid of commonly held myths. Contact aims to provide a human face on
mental illness and hope that treatment works. Protest aims to hold back biased
messages and challenges commonly held images of mental illness. In some situations,
education and contact has been found to be an effective strategy to use to reduce
mental health stigma among youth (Schulze et al., 2003). In addition, there is research
to suggest that multi-faceted mental health promotion programs focused on preventing
mental illness are effective.(McEwan et al., 2007; Weist & Murray, 2007; Wells et al.,
2003).
Youth Net Hamilton is a community-based youth mental health promotion program that
aims to increase awareness of mental health issues, decrease stigma towards mental
illness and increase help seeking behaviours through group discussions with youth and
screening of at-risk youth. Each Youth Net Focus Groups (YNFG) is facilitated by
trained youth leaders and follows a standard format by asking participants four starter
questions: 1) What is mental health? 2) What is mental illness? 3) What are some things
that are stressful for you? 4) What do you do to cope with stress? At the end of the
session, youth are given a “Youth Service Guide” and those identified as at risk are
referred for follow up. As this program has existed for 8 years and has not been
evaluated, a collaborative partnership was developed to evaluate the effectiveness of
the program in decreasing stigma towards mental illness and changing how youth seek
help for mental health problems.
Research Questions
To evaluate the impact of the program on mental illness stigma among youth, five
research questions were developed.
1
The primary research question was: Does stigma towards mental illness decrease for
youth 13 to 18 years old after participating in school-based Youth Net Hamilton Focus
Groups (YNFGs)?
Secondary Research questions included:
• Do participants (youth) who have lower stigma scores assist (help) their peers to
seek personal or professional help more than participants (youth) with higher
stigma scores?
• Is there a relationship between stigma scores and helping behaviours after
participation in YNFGs?
• Is willingness to seek help [at time 2] among participants (youth) with mental
health problem(s) related to participation in YNFGs?
• Is there a difference in the expenditures for Health and Social Service Utilization
(HSSU) in participants with and without mental health problems between the
YNFG participants and participants in the control group?
Methods
There were six schools involved in the study, two low needs, two medium needs and two
high needs, as identified through indicators such as income, literacy, student mobility
and poverty used by the local school board. There were 294 youth who participated in
the study. Using randomization, one half the participants received the YNFGs
(intervention group) and one half did not (control group). Researchers measured
changes in stigma, mental health problems, feelings and behaviours, and health and
social service utilization both before the YNFGs and one month following the
intervention. In addition we asked YN facilitators to record key comments both from
participants and themselves to assist us in understanding what was discussed during the
focus groups. Some of the limitations of the study are that we had a lower than
expected student participation rate and limited information about the nature of the
discussions that took place during the groups since they were not audio-recorded.
Findings
The overall study goal was to evaluate the impact of participation in YNFGs on mental
illness stigma. Although stigma did not decrease overall for study participants, there was
less of an increase in the intervention group suggesting that YNFGs be considered a
harm reduction approach. For females in the YNFGs, we found a 12.5 % difference that
we think is clinically relevant. We also found that for youth attending low need schools,
there was a significant decrease in stigma after participating in YNFGs for both males
and females, but especially males. This finding supports our first research question for
this particular population.
An interesting finding was that for all study participants, stigma score changes were
worse for grade 10 participants, particularly males leading us to consider the potential
program impact.
Our qualitative findings (from recorded comments) demonstrated that focus group
participants could not clearly distinguish between mental health and mental illness and
that youth in high need schools reported more negative coping strategies and more
mental health problems. It was unclear how often the “youth services guide” was
discussed during the focus groups.
2
We did not find that youth with lower stigma or youth who participated in the focus group
helped their peers more than youth with higher stigma or in the control group. However,
girls helped more than boys and that youth in general helped peers seek more personal
help (30%) than professional help (7%).
We expected that youth with mental health problems who participated in the focus
groups would be more willing to seek help, but we found no difference. We did find that
mental health problems (as measured by depression) in youth were higher than
previously reported with 9.5% with very elevated for mental health problems, 22% with
somewhat elevated mental health problems and 68% reporting minimal mental health
problems.
Lastly, we examined the costs associated with use of health and social services by
group and level of school need. Consistently across all groups students with mental
health problems had higher HSSU expenditures than students without mental health
problems. Furthermore, we found higher costs for students from high need schools as
compared to students from other schools. We also found the lowest level of health and
social service use by students in medium need schools.
Implications for Practice and Policy
The results of the study, when considered along with the literature review that was
conducted have led to the development of a number of practice recommendations
regarding program delivery, youth involvement and the broader community. We
recommend that:
•
•
•
•
•
YNFGs continue “as is” in low need schools and that there be consistency
among facilitators when community resources are discussed and the “guide” is
distributed.
A second session using a contact or an interactive component be added to the
program in medium and high need schools.
The inclusion of targeted interventions be explored in high need schools.
Youth be involved directly in the program through the provision of input and that
a youth governance model is implemented.
Youth Net Hamilton influence mental health service planning for youth at a local
level through sharing research findings and advocating for youth involvement.
Conclusions
It is very difficult to reduce both stigma towards mental illness and barriers toward help
seeking because of the complexity of factors that cause stigma and act as barriers.
Our study found the YNFG intervention was effective in decreasing stigma in participants
attending low need schools, and was suggestive that YNFGs are marginally more
effective for girls than boys. Stigma did not impact on help giving. The YNFG
intervention did not affect help seeking for those with mental health problems. Lastly,
health and social service utilization expenditures were higher for those with mental
health problems, especially in high need schools. The link between lower stigma and
increased help seeking behaviours for youth with mental health problems could not be
3
answered by this study. Furthermore, because of methodological limitations, we need to
be guarded in generalizing our study results.
Youth Net is one strategy to address decreasing stigma. However in order to be most
effective it must be part of a comprehensive anti stigma strategy that could include the
whole school, media, and legislative changes that would occur over an extended period
of time.
4
1. Introduction
a. Background Information / Literature Review
Mental health problems in adolescents are an important population health issue. Using
data from the National Population Health Survey (NPHS), Stephens, Dulberg and
Joubert (2000), found that youth (12-19 years old) had the lowest prevalence of positive
mental health and the highest prevalence of mental health problems. Mental health
problems among children and youth are predicted to increase 50% by the year 2020
(European Commission, 2004).
In their call to action, the Canadian Pediatric Society (Canadian Pediatric Society, 2006)
highlighted two issues relevant to this study. First, they identified a need to implement
mental health awareness programs that include early mental health risk factor
identification and stigma reduction, and second, they identified a need to increase
research capacity and resources for children’s mental health. These needs are included
in the Reaching for the Top report by the Advisor on Healthy Children and Youth (Leitch,
2007) as well, along with recommendations to create a national focus on child and youth
mental health issues, ensure appropriate access to care at multiple levels, build health
human resource capacity in paediatric mental health, create a research focus on
paediatric mental health, increase awareness and reduce stigma through public
education, and effectively intervene and reduce suicide rates among Canadian youth.
Additionally, there is evidence to suggest that multi-faceted mental health promotion
programs focused on preventing mental illness are effective (McEwan et al., 2007; Weist
& Murray, 2007; Wells et al., 2003). Mental health researchers can play an important
role in helping those suffering from mental health illnesses by providing objective
evaluation of methods used in reducing mental illness stigma (Corrigan, 2004a). In
particular Watson, Miller, and Lyons (2005) have noted a dearth of investigations
targeting interventions used to attenuate the effect stigma has in adolescents with
mental illness.
This research project directly addresses the gaps in knowledge by creating a
collaborative partnership between McMaster University, the City of Hamilton, Youth Net
Hamilton, Alternatives for Youth, and the Hamilton-Wentworth District School Board to
ask: Does stigma towards mental illness decrease for youth 13 to 18 years old after
participating in the school-based Youth Net Hamilton focus groups (YNFGs)?
Four areas are addressed in this literature review: the definition of stigma; the stigma of
mental illness; the effect of stigma on help-seeking behaviours; and interventions that
can be used to reduce the stigma of mental illness.
What is stigma?
Stigma is a complex phenomenon. In his seminal text, Notes of the Management of a
Spoiled Identity, Goffman (1963) distinguished between stigmas that are readily
perceived (like ethnic group) versus those that might be hidden (like sexual orientation or
religion). Mental health stigma falls into the second category. According to the UPenn
Collaborative on Community Integration (UPenn Collaborative on Community
Integration, 2008), “stigma is a common term that refers to a broad set of negative
beliefs, prejudices, and discrimination that are associated with mental illnesses”. Stigma
can also be defined as “cues that elicit stereotypes” (Corrigan, 2004a), p.615.
5
Stereotypes in turn, are those social labels that are used to quickly categorize groups of
persons by attaching certain accepted ideas to the group (Corrigan, 2004b; Schumacher
et al., 2003). When stigma describes the beliefs of those people who are not part of the
stigmatized group, the problem does not lie with the individuals who are being
stereotyped, but with those who harbour the prejudice (Corrigan & Penn, 1999). Stigma
often affects interactions with persons with mental illness negatively, and may affect
those with the prejudice by reducing their willingness to seek help should they need to in
the future (Cooper et al., 2003; Corrigan & Watson, 2002; Wrigley et al., 2005). For all
individuals, both with and without mental illness, perceived stigma refers to the belief
that other people hold stigmatizing ideals (Barney et al., 2005).Finally, self-stigma occurs
when people with mental illness have negative attitudes about themselves due to
internalizing stigmatizing ideas held by society.
Mental Health Stigma
The stigma of mental illness is potentiated by the media when children’s television uses
derogatory terms such as “nuts, bananas, twisted, wacko, and cuckoo” to describe
mental illness (Byrne, 2001). Films and television also depict mental illness as either
something to be laughed at, feared, or pitied (Byrne, 2000; Corrigan, 2004a; Corrigan et
al., 2004; Watson et al., 2004). These negative attitudes continue to increase with age,
suggesting that stigma shown by adults is rooted in early childhood (Watson et al.,
2004). These stigmatizing attitudes are apparent in most Western nations and are
widely endorsed by the general public (Corrigan & Penn, 1999; Corrigan & Watson,
2002; Schumacher et al., 2003).
The last decade has seen many different groups focus on the process of stigma as
related to mental illness (Corrigan et al., 2004). Organizations from around he world
(e.g., the government of the United Kingdom, the Royal College of Psychiatrists, the US
Surgeon General, and the World Psychiatric Association) have set initiatives in motion to
research the issues of stigma and mental illness and to begin the battle against stigma
(Byrne, 2000; Corrigan & Penn, 1999; Smith, 2002). In Canada, in May 2006, a Senate
committee chaired by Senator Michael Kirby released a comprehensive report on mental
health and mental illness in Canada stating “children and youth are at a significant
disadvantage when compared to other demographic groups” (Kirby & Keon, 2006).
Quirion (2006) from CIHR suggests the fear of being labeled as having a mental health
problem prevents people from acknowledging there is a problem, seeking help, and
being open about their treatment.
Stigma and Help-seeking Behaviours
People who may benefit from mental health services often do not seek services (Browne
et al., 2004; Davidson & Manion, 1996; Royal College of Psychiatrists, 1995). In two
nationwide epidemiological studies, findings suggest 50 to 60% of people who would
benefit from treatment do not seek it (Kessler et al., 2001; Regier et al., 1993).
It is essential stigma be decreased by changing attitudes regarding mental illness, not
only for those affected by mental illness but also for those who are not (Corrigan & Penn,
1999). For college students (Cooper et al., 2003), and randomly selected community
residents (Wrigley et al., 2005), those who believe there is stigma associated with
mental illness have reported a decreased likelihood of seeking help if the need should
arise in the future. Those persons who suffer from mental illness may choose not to
seek treatment in order to avoid the stigma and associated prejudice (Byrne, 2001;
6
Cooper et al., 2003; Corrigan, 2004b; Mann & Himelein, 2004; Wrigley et al., 2005) or
may drop out of treatment because of perceived stigma (Edlund et al., 2002).
Barney, Griffiths, Jorm & Christensen (Barney et al., 2005), using survey methodology,
indicated that perceived stigma and self stigma were both associated with a decreased
likelihood of seeking help from all sources. The incidence of others’ views seems to play
a crucial role in help-seeking behaviour, with recommendations from significant others
as an important factor for those who have sought professional help. However, there was
a 19% response rate (n=1312), most were adults and 55% had a history of previous
depression. Using a cross-sectional survey of adults, Wrigley, Jackson, Judd & Komiti
(Wrigley et al., 2005) examined the role of stigma and attitudes toward help-seeking in a
rural population in Australia (28.4% response rate). There was no significant difference
for adults related to symptoms and help-seeking. Decreased perceived stigma was
associated with more help-seeking behaviours. Higher stigma scores were related to
more negative attitudes towards help-seeking behaviours.
Mental illness stigma is so great among youth that knowledge and treatment of mental
health problems is “significantly impeded” (Manion et al., 1997 p.111). Rapee et al.
(2006) researched a universal and targeted program to prevent depression in
adolescents in Australia. After controlling for mode of delivery, stigma was associated
with being male and those with higher levels of externalizing symptoms. Timlin-Scalera,
Ponterotto, Blumberg & Jackson (Timlin-Scalera et al., 2003) conducted a grounded
theory study exploring the help-seeking behaviours of white middle class high school
students. Their findings suggest males feel a high need to fit in and this contributes to a
gender-linked stigma about males’ help-seeking behaviours. When help was sought, it
was from friends.
In a review of mental health services for children and youth in Ontario, McMaster
University System Linked Research Unit identified “an enormous stigma surrounding
mental health” as a barrier to service (Browne et al., 2004). The reduction of this stigma
would facilitate treatment for mental health problems (Browne et al., 2004; Byrne, 2000;
Byrne, 2001; Cooper et al., 2003; Corrigan & Penn, 1999; Corrigan et al., 2005a;
Davidson & Manion, 1996; Esters et al., 1998; Kessler et al., 2001; Mann & Himelein,
2004; Naylor et al., 2002; Pinfold et al., 2003; Schulze et al., 2003; Shah, 2004; Watson
et al., 2004).
Mental Health Stigma Interventions
Stigma reduction interventions are often classified as having three different approaches;
education, contact based or protest that may sometimes be used in combination
(Corrigan & Penn, 1999). Education seeks to dispel commonly held myths about mental
illness; contact seeks to put a human face on mental illness. Protest seeks to suppress
discriminatory messages and challenge commonly held stigmatizing images, however it
can sometimes rebound and increase stigma (Corrigan & Penn, 1999; Martin &
Johnston, 2007).
Interventions that address reducing stigma to prevent mental health problems suggest
that reducing the stigma of mental illness is an effective health promotion strategy that
facilitates youth learning that they have common mental health issues and also
increases the likelihood that those youth who experience mental health problems will
seek support (Manion et al., 1997). It is suggested that education programs will help
decrease the stigma of mental illness, especially in children and adolescents
7
(Schulze et al., 2003). “Explicit conceptions of personality traits which are the basis for
the formation of stereotypes about groups of people are not developed until
adolescence. Projects with children and young people therefore appear to be a
particularly promising intervention” (Schulze et al., 2003), p. 142. Esters et al (1998) p.
470 state that “adolescence is a prime time to influence attitudes related to mental
illness and help-seeking, especially since few adolescents perceive therapeutic methods
as an option when faced with emotional problems.” Within the breath of educational
strategies to decrease stigma towards severe mental illness, Corrigan and Penn (1999)
report that education programs which provide facts about mental illness with peer
discussions have a greater likelihood that the participants will remember the correct
information and reject false assumptions.
Pinfold (Pinfold et al., 2003) examined decreasing mental health stigma and
discrimination in high schools in the United Kingdom. They found educational sessions
with young people can be a useful strategy to decrease stigma. Females responded
more positively than male students. There was a 73% response rate; however there
was no control group.
Based on a model established in Ottawa Ontario, Youth Net Hamilton is a communitybased youth mental health promotion program that aims to increase awareness of
mental health issues, decrease stigma towards mental illness and increase help seeking
behaviours. It is not an approach that exclusively uses education, contact nor protest
rather, youth have the opportunity to talk about issues that are important to them through
a group discussion format with older youth. Screening of at-risk youth is also included
as a component of the program (Davidson et al., 2006b). Each Youth Net Focus Group
(YNFG) is facilitated by trained youth leaders and follows a standard format by asking
participants four starter questions: 1) What is mental health? 2) What is mental illness?
3) What are some things that are stressful for you? 4) What do you do to cope with
stress? At the end of the session, youth are given a “Youth Service Guide” and those
identified as at risk are referred for follow up. Although offered in schools and
community groups by request for the past eight years, the program has not been
thoroughly evaluated. The current researchers conducted a pilot study in the fall of 2006
in one school in Hamilton to test the feasibility of carrying out the full study. The study
response rate was 70% and researchers found it was feasible to complete the full study.
This research study will add to the body of knowledge of interventions that aims to
reduce stigma and decrease barriers to youth seeking help for mental health problems
and will also take a preliminary look at health and social service utilization.
b. Project Partners
Project Team:
Person
Dr. Linda O’Mara
Organization
Role/Responsibility
McMaster University
Co-Principal Investigator, hired
project co-ordinator, obtained ethics
approval, co ran research meetings,
oversaw the running of the study,
worked with data analyst and
statistician concerning data analysis,
wrote up draft findings and draft
report
8
Project Team:
Person
Daina Mueller
Organization
Role/Responsibility
City of Hamilton
Lorraine Grypstra
Youth Net Hamilton
Catherine
McPherson-Doe
Alternatives for Youth
Cheryl Vrkljan
Centre for Addiction
and Mental Health
Rachel Harvey
McMaster University
Dr. Gina Browne
McMaster University
Co-Principal Investigator, hired
project co-ordinator, negotiated with
principal in high need schools re
supporting strategies for data
collection, supervised Youth Net
program, participated in Steering
committee, co ran research
meetings, drafted qualitative report
on YNFG recordings, collaborated
with community team members and
drafted parts of final report.
Youth Net Coordinator facilitated the
running of all Youth Net focus groups
(train Youth Net focus group
Facilitators, follow up with all
students referred for service) for the
period of the study. Co investigator,
liaised with research coordinator and
assisted in recruiting more study
participants, attended research team
meetings. Provided input and
feedback to final report.
Co-investigator. In the proposal
stage, supported the program as a
member of the Youth Net Hamilton
Coalition, participated in research
team meetings bringing her agency’s
perspectives to project. Left prior to
the start of the RCT.
Replaced Catherine McPherson-Doe
as co-investigator and Youth Net
Hamilton Coalition representative
during the actual study. - See role
above. Provided input and feedback
to final report.
Research coordinator. Managed the
overall running of the study, trained
data collectors, and worked with the
primary co investigators and the
Youth Net Coordinator to ensure the
study was completed as planned.
Worked diligently recruiting
participants. Provided input and
feedback to final report.
Methodologist / co-investigator.
Attended research team meetings
and offered methodological and
clinical expertise. Provided input and
9
Project Team:
Person
Organization
Dr. Noori AkhtarDanesh
McMaster University
Malcolm Powell
Hamilton-Wentworth
District School Board
David Hoy
Hamilton-Wentworth
District School Board
Role/Responsibility
feedback to final report.
Statistician / co-investigator. Offered
expertise for data analysis and did
intraclass correlations analysis.
Attended research meetings. .
Provided input and feedback to final
report.
Co-investigator. Attended research
meetings, offered School Board
perspective on feasibility issues, and
facilitated entry to participating
schools. Retired in summer 2008.
Replaced Malcolm Powell as coinvestigator and Hamilton-Wentworth
District School Board representative.
Attended research team meetings in
September and provided school
board feedback on implications of
findings. Provided input and
feedback to final report.
c. Research Questions
Primary Goal:
To evaluate the impact of participation in Youth Net focus groups on mental illness
stigma.
Primary Research question:
1. Does stigma towards mental illness decrease for youth 13 to 18 years old after
participating in school-based Youth Net Hamilton focus groups (YNFGs)?
Secondary Research questions:
2. Do participants who have lower stigma scores assist their peers to seek personal
or professional help more than participants with higher stigma scores?
3. Is there an interaction between participation in YNFGs and change in stigma
score in explaining helping behaviours?
4. Is willingness to seek help [at time 2] among participants with mental health
problem(s) related to participation in YNFGs?
5. Is there a difference in the expenditures for Health and Social Service Utilization
(HSSU) in participants with and without mental health problems between the
YNFG participants and participants in the control group?
10
2. Methods
a. Study Design
A prospective single blind randomized trial using concealment was used in this study. In
each participating school, grade nine and grade ten classrooms were randomly selected
to either the control or intervention group. The control classrooms received the
intervention after conclusion of the study. The final sample included 294 students
(137 control, 157 intervention).
b. Inclusion/Exclusion Criteria
All students in participating classrooms who agreed to participate were included in the
study. There were no exclusion criteria.
c. Recruitment
School recruitment started in spring 2007. The goal was to enroll six schools in the
study, two low need, two medium need, and two high need schools. Need level was
assessed by the Hamilton-Wentworth District School Board (HWDSB) and was based on
selected social demographic variables such as income, poverty rates, and student
mobility as reported by Statistics Canada census data (M. Powell, personal
communication, January 24, 2007). The Youth Net Coordinator promoted the program
in all high schools in the HWDSB. A letter inviting principals to support the research
project was sent to all potential participating schools at the beginning of the school year.
When schools requested the program, the Youth Net Coordinator ensured there were at
least two eligible classes in each school. We recruited students from 6 schools, but
needed to solicit participants from 24 classrooms from the 6 schools in order to meet our
sample size requirements. Furthermore, the data collection period needed to be
extended to recruit more participants. Data collection extended from November 2007 to
May 2008.
d. Procedure
Information packages containing the study information sheet and informed consent form
for the study participants were delivered to each teacher whose class was participating
in the study. Teachers were responsible for distributing these packages and were
remunerated with a $20.00 bookstore gift certificate.
Consent/assent forms were returned to the data collector and all students returning
signed or unsigned forms received a $2.00 coffee shop coupon. Time 1 data collection
sessions were scheduled following the return of the consent forms. In these sessions,
participating students completed the four study questionnaires and a brief demographic
questionnaire. This required approximately 25 minutes to complete. In certain
circumstances where participants had difficulty reading or understanding the
questionnaire, the data collector would read the questionnaire aloud or provide standard
definitions for words or concepts that were confusing to the students.
11
The day following Time 1 data collection, the intervention groups participated in the
Youth Net Focus Group (YNFG). Four weeks after the focus group intervention Time 2
data collection took place. This session involved completion of the four study
questionnaires and assistance to students having difficulty reading or understanding the
questionnaires was provided. The students were remunerated with a $10.00 movie
coupon following each data collection session.
e. Intervention
Youth Net focus groups follow a standard format. Focus groups take place during a
regular class period and last approximately 75 minutes. Two focus group facilitators
start each session by reviewing the focus group format and explaining the concept and
limitations of confidentiality. Student participants then sign a consent form and complete
Youth Net Survey. The discussion was led by the facilitators through asking four starter
questions and facilitate discussion based on participants' responses. The starter
questions are: 1) What is mental health? 2) What is mental illness? 3) What are some
things that are stressful for you? 4) What do you do to cope with stress? Each student
then receives a Youth Services Guide listing local community support services available
for youth and completes a participant satisfaction survey. In order to assess risk, the
facilitators have follow-up conversations with each student for whom concerns were
identified either on their survey or during the discussion. Notes are taken by focus group
facilitators to record program fidelity (see Appendix).
f. Measures
Participants were asked to complete four study questionnaires (the Stigma scale, the
Mental Health scale, the Feelings and Behaviours scale, and the Health and Social
Services Utilization questionnaire) at Time 1 (baseline - the day before the YNFG) and at
Time 2 (follow up - four weeks following baseline). Demographic information was
collected at Time 1 (age, sex, country of parents’ birth). The study instruments are
included in the appendix.
Stigma Scale - Attribution Questionnaire Revised (AQr) - Short Form for Children and
Youth:
This questionnaire is based on the original Attribution Questionnaire (AQ) consisting of
27 items measuring nine factors, using three items per factor: pity, dangerousness, fear,
responsibility, segregation, anger, help, avoidance, and help-seeking on a nine-point
agreement scale. The factor structure and reliability of the AQ were validated in two
confirmatory factor analyses (Cooper et al., 2003; Corrigan & Watson, 2002; Corrigan et
al., 2003). Tool developers revised the form for children and youth. Based on previous
confirmatory factor analysis, and Corrigan and colleagues (Corrigan et al., 2005a) chose
the single item that loaded most highly on each factor and incorporated them into the
AQr. The current scale has 9 items. The first eight items represent the constructs in the
attribution and dangerousness models of mental illness stigma - responsibility/blame,
anger, pity, help, dangerousness, fear, avoidance and segregation. The ninth item
addresses an additional construct; whether youth will seek mental health services if they
are in need. Items are measured on a nine-point scale. The pity, help, and help-seeking
items are reversed scored. Total scores are calculated for items one to eight
(P. Corrigan, personal communication, December 3, 2006).
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Mental Health Scale:
The National Longitudinal Study of Children and Youth (NLSCY) was used for both the
mental health scale and the feelings and behaviours scale. The NLSCY captures the
experience of children and youth growing up in Canada. Information is collected every
two years on the same children on a variety of outcomes (health, language, cognition,
social, emotional, and behavioural) and determinants (family, school, environments,
validity testing). Scales are validated for every cycle by an expert panel that recommend
reliable and valid measures of the above constructs. Factor analysis is computed for the
data in each cycle.
The mental health rating scale is aimed at gathering information about the mental health
of respondents with particular emphasis on symptoms of depression. It was proposed
that this section focus on depression for the following reasons: depression is a prevalent
condition; present research on this subject is generally based on demonstration groups
and not on population samples; and it is felt that introducing policies in this area could
make a difference (National Longitudinal Survey of Children and Youth Health Survey
(NLSCY), 1999, p. 105). Cronbach’s α was reported as 0.82 (National Longitudinal
Survey of Children and Youth Health Survey (NLSCY), 1999, p. 106). Poulin, Hand &
Boudreau (Poulin et al., 2005) reported on validation data for this tool with an adolescent
population. They identified a score of 0-11 as minimal, 12-20 as somewhat elevated and
21-36 as very elevated for depressive symptoms.
Feelings and Behaviours Scale:
The objective of the feelings and behaviour scale is to assess aspects of the behaviour
of youth 14 to 17 years of age. The questionnaire measures six factors, with the
following Chronbach’s α for reliability: indirect aggression (0.728), Emotional
disorder/anxiety (0.760), physical aggression (0.738), hyperactive/inattentive (0.751),
prosocial (0.766) and property offenses (0.623)(National Longitudinal Survey of Children
and Youth Health Survey (NLSCY), 1999). Although this tool is not being used to test
study hypotheses, it does measure emotional and behavioural problems, which were
present in the pilot study.
Health and Social Services Utilization Questionnaire (HSSU):
Health and social service use was measured with an inventory developed initially by
Browne, (Browne et al., 1985). The current version, now called the Expenditures for
Health and Social Service Utilization Questionnaire (Browne et al., 2001) has
consistently distinguished expenditures for use of services by youth: with and without
behaviour problems; with and without mental illness; with and without a range of chronic
diseases; and with and without poverty. It consists of questions about the respondent’s
use of eight categories of direct health services: primary care; emergency room;
specialists; hospital episodes; hospital days (irrespective of episode); emergency room
specialists; seven types of other community health professionals; and laboratory
services. This approach to the measurement of costs is available upon request and was
recently acknowledged by Guerriere et al. (Guerriere et al., 2006) as one of the few
measures of ambulatory utilization published and empirically validated. Retrospective
recall data was used to assess the participant’s use of all health services. Inquiries were
constrained to the reliable duration of recall for specific events – six months for
remembering a hospitalization, two weeks for a visit to a physician, and two days for the
consumption of medications. To calculate annual utilization measures, the various
spans of time were normalized to yield an annual rate of utilization per category of health
service (Spitzer et al., 1976).
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In addition, two questions about opportunities youth had in helping a friend (who was
suffering from stress or other mental health issues) seek personal or professional help
were added.
g. Data Analysis
Descriptive statistics were calculated for all dependent and demographic variables.
Group comparisons with nominal data were analysed using the (2 statistic. For each
research question, intraclass correlations (ICC) were calculated to determine if the
hierarchical nature of the data (i.e., students nested within classes) needed to be
considered in the analyses. Where the ICC was large or significant, multilevel modeling
was used. If the ICC was small or insignificant then analysis of covariance (ANCOVA)
and t-tests were used. STATA was used to calculate ICC and all other statistics were
generated using SPSS.
h. Ethics
The study was approved by the McMaster University Research Ethics Board and the
Hamilton-Wentworth District School Board Research Ethics Board. The primary ethical
issue was that students may identify that they were at risk of mental health issues such
as depression. All students identified at risk were followed up by the Youth Net
coordinator, assessed, and then referred to community services such as mental health
emergency services or in-school support services. This is usual Youth Net practice. For
study purposes, the following considerations were addressed: participation was
voluntary; refusal to participate did not affect the student’s classroom activities;
participants were fully informed of the nature of the study and of their rights and
obligations; signed, informed consent was obtained from all participants and parents
when participants were less than 18 years old; and participants were assured that their
information would be kept confidential.
i. Challenges
While most teachers volunteered their classes for participation in Youth Net focus
groups, some teachers were volunteered by their principals, which resulted in lower
student participation rates in those classrooms. In addition, students both in the
intervention and control groups in one school had low literacy levels and strategies such
as preparing overheads of the research questions, reading the questions out loud to
participants and clarifying questions were utilized. There was some evidence of rapid
questionnaire completion in medium need schools however, all questionnaires were
reviewed for patterning of responses and none were found.
Students were also suspicious of the collection of HSSU information and requested
explanations as to why they were being asked personal information. Data collectors
explained that the HSSU questions were determining the cost of participants’ use of
health and social services. Students frequently asked what data collectors were going to
do with their answers.
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3. Results
Study findings are organized as follows: First, results are presented comparing study
participants to non-participants. Second, study participants are compared to study drop
outs. Third, students in the intervention group and the control group are compared at
baseline. Fourth, the research questions are then answered with supporting data.
Lastly, a qualitative report of the analysis of the Youth Net facilitator recordings of the
focus groups is presented.
a. Study Participation Rate
Six schools (two low need, two medium need and two high need), 24 classrooms and
294 students were involved in this study (see figure 1 in appendix).
Overall, 54% of potential participants agreed to take part in the study (294 of 546). This
is lower than the 70% participation rate found in the pilot study. The participation rate
was 44% in high need schools, 53% in medium need schools, and 64% in low need
schools (see Table 1 in appendix).
The ratio of male to female was not different between the study participants and nonparticipants (see Table 2).
1. Study Dropouts
There were 26 participants that did not complete the study resulting in a 91% overall
completion rate. Contrasting the type of school, 89% completed the study in the high
need schools, 91% in the low need schools, and 93% in medium need schools (see
Table 1). Again, differences in drop-out rates between males and females were
examined and 9% for both sexes dropped out of the study (see Table 3 in appendix).
2. Baseline Comparisons: Control and intervention groups
The control group was compared to the intervention group at baseline on demographic
variables and the study questionnaires. Significant differences in grade level composition
were found (χ2 (4, N=290) = 31.35, p < .001). The control group was comprised of
64.7% grade nine students whereas the intervention group included 91.6% grade nine
students.
In addition, some grade nine classes who volunteered for the study were gender
specific, leading to an uneven numbers of males and females in the control and
intervention groups. The control group consisted of 45.3% female participants while the
intervention group registered 66.9% female participants ((2 (4, N=294) = 13.94, p <
.001).
Largely, the study participants and their parents were born in Canada. Overall, 72 % of
study participants’ mothers were born in Canada whereas only 26% were born outside of
Canada. Similarly, 65% of study participants’ fathers were born in Canada while only
30% were born outside of Canada. Overall, 86% of study participants were born in
Canada and 13% were born outside of Canada.
15
There were no statistically significant differences between the groups on birth location
for either parents or participants (see Table 4).
There were no statistically significant differences between the control and experimental
groups on three of the four study questionnaires; stigma, mental health, and feelings and
behaviours at baseline (see Tables 5 and 6). However, the prevalence of mental health
problems by school status (low, medium or high need) was different with participants in
low need schools having fewer severe mental health problems and participants in high
need schools having fewer students with no mental health problems, both at baseline for
all study participants (see Table 7) and for study completers, (see Table 8).
Lastly, there were significant differences at baseline on the HSSU questionnaire
between the control and intervention groups (see Table 9). Participants in the control
group had more HSSU total costs than participants in the intervention group.
Additionally, HSSU expenditures for study completers were twice the total of study dropouts (see Table 10).
b. Research Question Results
1. Primary Research question
Does stigma towards mental illness decrease for youth 13 to 18 years old after
participating in school-based Youth Net Hamilton focus groups (YNFGs)?
The ICC for stigma score change was small indicating that variation associated with
class membership was small (( = 0.016, p=.40). Thus an ANCOVA procedure was used
to assess differences in stigma change scores among group (control, intervention),
school status (low, medium, & high need), gender (male, female), and grade (grade 9,
grade 10) while controlling for baseline stigma scores. The strongest predictor of stigma
change scores was the covariate stigma score at baseline (F(1,245) = 37.74, p<.001).
Main effects were found for group (F(1,245) = 4.40, p=.037) and grade (F(1,245) = 5.92,
p=.016). Gender was marginally significant (F(1,245) = 3.53, p=.061). There was an
overall negative change score (-0.81) indicating that over the course of the project,
stigma scores increased. Mean change scores between groups demonstrated less of an
increase in stigma scores at follow-up for those participants taking part in the YNFG (M =
-0.16) compared to participants in the control group (M = -1.53). Participants in grade
nine (M = -0.34) had significantly smaller increases in stigma scores relative to those
students in grade ten (M = -2.63). While both genders had an increase in stigma score
from baseline to follow-up, male participants (M = -1.44) had significantly larger stigma
score changes than female participants (M = -0.32). The ANCOVA procedure also
uncovered an interaction between gender and grade (F(1,245) = 5.11, p=.025). Mean
comparisons using Tukey's HSD indicated that male students in grade ten (M = -4.10)
had significantly greater increases in stigma scores from baseline to follow-up than both
male and female students in grade nine (male M = -0.56; female M = -0.20) and
marginally greater change scores than female students in grade ten (M = -0.79).
Examination of mean change scores for male and female participants in each
intervention group showed a positive change score for women in the intervention group.
While the group by gender interaction was not statistically significant, a clinical difference
(change score difference (0.31 + 1.44) / control group baseline (13.98) x 100%) of
12.52% is relevant.
16
Main effects and interactions involving school status (high, medium, and low need) were
not significant in the main analysis, however; due to the differences in the types of
students attending each school closer examination of these different school
classifications is merited. Separate analyses were performed for students within each
school status to examine the effectiveness of the YNFG programme. ANCOVA
procedures did not find any significant effects for group, gender, or grade within both
high-need and medium-need schools. The analysis within low-need schools showed a
significant main effect for group (F(1,96)= 14.45, p<.001) with those students
participating in the YNFG having a lower stigma score at follow-up compared to baseline
(M = 0.54) and those in the control group with a greater stigma score at follow-up
compared to baseline (M = -1.82). The procedure also detected an interaction between
group and gender (F(1,96)=5.38, p=.02). Tukey's HSD showed that the difference was
between the intervention and control group for male students with a significant drop in
stigma score from baseline to follow-up for those in the intervention (M = 3.06) compared
to those in the control group (M = -1.83). Female students in both intervention and
control groups were not different from each other or the male participants
(Female-Control M = -1.79; Female-Intervention M = 0.54).
2. Secondary Research questions
Do participants who have lower stigma scores assist their peers to seek a) personal or
b) professional help more than participants with higher stigma scores?
Personally assisting peers was measured by question HS7 (In the past month, have you
tried to be supportive to a friend or classmate who is suffering from stress or other
mental health issues?). The ICC for personal help was statistically significant (ρ = 0.135,
p = .03).
Therefore a multilevel logistic model was used to answer this research question.
Estimates with their standard errors and p values are reported. At baseline, 30% of all
study participants reported helping their peers seek personal help. The analysis
indicated that personally helping peers seek help at follow-up was not dependent on
stigma score at baseline (0.0221 (0.0198), p=.26), was marginally significant for grade
level (-0.825 (0.4456), p=.064) and statistically significant for gender (-.877 (0.3878), p=.
02). Females were 2.4 times more likely to help their peers than males.
Assisting their peers to seek professional help was measured by question HS8 (In the
past month, have you assisted a friend or classmate to seek professional help, for
example, from a doctor, counsellor, or nurse, for stress or other mental health issues?).
The ICC for professional help was statistically significant (ρ = .233, p<.001) and
multilevel logistic regression was used to address the research question.
At baseline, 7% of study participants reported assisting their peers to seek professional
help. Assisting peers to seek professional help at follow-up was not dependent on
stigma scores (-0.3136 (.03457), p=.36) yet was dependent on grade level (-1.66708
(0.68128), p=.01). Students in grade ten were 5.3 times more likely to help their peers
seek professional help than students in grade 9.
To assess if school status was important in determining helping behaviour for both
personal and professional help, school status was set as the level two grouping variable
in a multilevel logistic regression model. For both dependent variables school status did
17
not account for a significant amount of variation (personal (ρ= 0.0, p=1.0); professional
(ρ=0.06, p=.20)).
3. Is there an interaction between participation in YNFGs and a change in stigma score
in explaining helping behaviours?
This research question was assessed using helping behaviour as the outcome measure
and a group by stigma change score interaction term as the predictor. As both helping
personally and finding professional help had significant ICC’s (see RQ2) multilevel
logistic regression models were used. Both analyses did not detect a significant
interaction between group and stigma change score (Personal (-0.004 (0.053), p = .95;
Professional (0.014 (0.103), p=.89).
4. Is willingness to seek help (at time 2) among participants with mental health
problem(s) related to participation in YNFGs?
Willingness to seek help was measured by a single question on the stigma questionnaire
(Imagine you were feeling depressed and having some problems at home. A month
later, you were still having difficulties and find yourself crying all the time, unable to sleep
much, and unable to pay attention at school. Would you be willing to see a counselor or
doctor to get help with your depression?) Only participants who scored 12 or greater on
the depression index were included in the analysis. The ICC was small (ρ = -0.03,
p=.41) thus, ANCOVA procedures were used to answer this question.
As willingness to seek help at follow-up was significantly affected by willingness to help
at baseline (F(1,68)=56.64, p<.001), the baseline score was used as a covariate. The
ANCOVA procedure failed to detect any differences in willingness to seek help between
participants with mental health problems in the YNFG group and participants with mental
health problems in the control group (F(1,68)= 1.12, p=.29).
5. Is there a difference in the expenditures for Health and Social Service Utilization
(HSSU) in participants with and without mental health problems between the YNFG
participants and participants in the control group?
The HSSU expenditures were measured both including hospitalization costs and
excluding hospitalization costs. The results were similar in both situations, although
including hospitalization costs increased overall HSSU expenditures. Since
hospitalization costs recall period was 6 months and this overlapped baseline and followup data collection periods (which were 1 month apart); expenditures including
hospitalization was not used in the analysis. The ICC for HSSU costs was statistically
significant (ρ = 0.184, p=.007).
There was a statistically significant difference at baseline in the HSSU expenditures
between the control and intervention groups. As well, the ICC associated with class
membership was statistically significant. However, our findings revealed that being in
the control group or the intervention group did not affect HSSU expenditures; the
expenditures at baseline affected expenditures at follow-up. Participants who had high
expenditures at baseline continued to have high expenditures at follow-up.
18
We reported a difference in expenditures for HSSU in participants with mental health
problems (as measured by a score of 12 or more on the mental health questionnaire and
without mental health problems (as measured by a score of 11 or less) using a projected
6-month duration cost analysis (see Table 11).
Direct costs for depressed participants were $2389.85 in the control group and $905.83
in the intervention group. Direct costs for non depressed participants were $869.98 in
the control group and $340.47 in the intervention group (p<.001). Participants who were
depressed used more HSSU. Participants in the control group, both depressed and not
depressed used more HSSU.
Using multilevel modeling procedures the analyses showed: 1) HSSU expenditure for
direct costs at follow-up (excluding hospitalization) was dependent on school status
(p=.004, see Table 12); 2) expenditures for family physician/ walk in clinics was
significant (p=.008, see table 13); and 3) expenditures for emergency rooms were
marginally significant (p=.058, see Table 14). In all situations, participants in high need
schools had higher expenditures than participants in lower need schools, both for
participants who were depressed and not depressed. An unexpected finding was that
HSSU expenditures were lowest in medium need schools.
A final analysis was done investigating the association the Feelings and Behaviours
measure with stigma scores. Pearson correlations were calculated between sub-scale
scores from the Feelings and Behaviours questionnaire and total stigma scores. A
statistically significant negative association between prosocial score and total stigma
score was found (r = -.422, p=.01). Thus, students with high prosocial scores had lower
stigma scores. The remaining sub scales of the Feelings and Behaviours questionnaire
were not significantly associated with total stigma scores (see Table 15).
c. Qualitative Report on Focus Group
Following each Youth Net focus group, facilitators were asked to describe the process of
the focus groups by completing the Focus Group Recording Form (see Appendix). The
purpose of collecting this information was to record program fidelity. The form
documented the gender and number of group participants, the main ideas presented by
participants when asked each FG question, the facilitator’s response to the main ideas
presented by participants, the number of individual “follows ups” upon completing the
group and the number of referrals made. Completed YNFG forms were compiled into
one file and then analyzed using content analysis to extract common themes discussed
among all groups.
As not all students participating in focus groups were enrolled in the study, the records
completed by the YNFG facilitators included information provided by both study and nonstudy participants. As this recording is considered part of program record keeping, it
was deemed appropriate to use all data recorded on the facilitators’ reports. Of the
forms completed, 49% had information that was missing and 17% of forms had
substantial missing information (5 or more questions not completed). Overall 440
students participated in the focus groups during the study time period, 37% of
participants were from low need schools, 39% were from medium need schools and
26% of participants were from high need schools. Of all participants in all schools, 47%
were male and 53% were female.
19
When program participants were asked to define mental health and mental illness,
overall, both male and female participants could not clearly distinguish between these
two concepts. Females, more so than males, demonstrated awareness of a difference
between the two terms. Documentation of facilitator responses to focus group
participants was limited. Of information documented, facilitators compare mental
health/illness to each other and to physical health/illness.
School type and gender of focus group participants did not have an impact on the type of
stressors experienced by participants. Stressors cited by participants include
family/parents, school, peer relationships, sports, work/career planning and health.
Facilitators tended to respond to participants by clarifying that stress can be positive, is
normal and can lead to illness. Some facilitators also shared personal stories about
stressors they have experienced and explored feelings aroused by stressors as well as
the importance of dealing with stress.
Female focus group participants tended to use quieter coping strategies such as crying,
talking with friends and going for a walk while male participants tended to list physically
oriented responses such as punching bags and sports. Both males and females
mentioned playing with pets and listening to music as methods they use coping with
stress. Participants from low need schools verbalized more positive coping strategies
such as talking with friends and sleep while participants from higher need schools cited
negative coping strategies. Drugs, alcohol, physical violence, personal harm were
among the negative coping strategies found among all participants. Responses by
facilitators to participants concerning coping strategies were very thorough. The benefits
of positive coping strategies and the limitations of negative coping strategies were
explored. Facilitators also lead the discussion to alternatives when only negative or
positive coping strategies were presented by participants.
As a component of standard program practice, at the onset of each focus group, each
participant is asked to complete the Youth Net Survey. This self assessment
questionnaire identifies students at risk of mental health concerns. In order to assess
risk, the facilitators have follow up conversations with any student(s) for whom concerns
were identified either on their survey or during the focus group discussions. During the
follow-up, the facilitator identifies the reason for the follow-up conversation with the
student. Of the 440 students participating in focus groups during the study, 35% of
participants required a follow up. Of these follow-ups, 23% were from low need schools
(37% of total population), 42% were from medium need schools (39% of total population)
and 35% were from high need schools (26% of total population). Of the 35% of students
requiring referral to other services, 49% were from high need schools, 32% were from
medium need schools and 19% were from low need schools. Clearly students from high
need schools received more follow up proportionally to their focus group participation
numbers.
4. Discussion
4a.The discussion will follow the research question format, with subheadings as
appropriate.
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1. Research Question 1
Mental Illness Stigma
The overall study goal was to evaluate the impact of participation in YNFGs on mental
illness stigma. Although stigma did not decrease overall for study participants, there
was less of an increase in the intervention group suggesting that YNFGs be considered
a harm reduction approach. As the intervention group did not get worse, we argue that
not having a deterioration in scores is clinically relevant.
Our qualitative data is limited as written focus group summaries are missing data. It is
unclear if mental health/mental illness constructs are consistently challenged or if
concepts were clarified during all group discussions. Thus the resulting impact on
stigma is unknown.
School Need and Mental Illness Stigma
For youth attending low need schools, there was a significant decrease in stigma after
participating in YNFGs. This finding supports a small dose intervention for low need
schools and suggests support for our first research question for this particular
population. Although both boys and girls improved in their stigma scores, the changes
for boys were even greater than for girls. This is an unexpected finding for youth in low
need schools.
We did not find information in the literature regarding anti stigma programs specifically
targeting students according to the level of need of the schools. However, evidence of
the higher reported incidence of mental health problems in youth attending high need
schools suggests the need for Youth Net to consider a more intensive approach for
participants in high need schools. Given that youth in high need schools have more
negative coping strategies, more mental health problems and have higher socio
demographic challenges, they may require targeted intervention.
Effect of Gender on Mental Illness Stigma
Females in the intervention group had a clinically relevant 12.5% decrease in stigma
scores compared to females in the control group. Other studies suggest females have
more decrease in stigma scores following education and contact (with an individual who
has experience mental health issues) and also show in greater improvements in social
distance (Pinfold et al., 2003; Rapee et al., 2006; Stuart, 2006).
Overall changes in stigma scores
Our study findings of worsening stigma scores for students (in both the intervention and
control groups) in grade 10, and especially for males in grade 10 is an important finding
with potential program implications. Does grade level make a difference? Chandra and
Minkovitch (Chandra & Minkovitz, 2006) also found higher stigma scores in males than
females.
Comparison to Other Mental Illness Stigma Reduction Programs
When examining the literature particularly on mental illness stigma and interventions
directed towards youth, we were unable to find studies of similar programs to Youth Net
in the peer reviewed literature. Davidson, Manion, Davidson & Brandon (Davidson et al.,
2006b) described a quality enhancement to the YN/RA program. They collaborated
with community youth and YN facilitators to increase the intervention to two focus
groups, but they did not empirically examine stigma reduction.
21
We also located a description of the Youth Net Ottawa program with their wide range of
health promotion activities (Davidson et al., 2006a) The authors identified the need to
examine program outcomes.
We can learn from stigma reduction programs that have interventions comprised of
education with contact as they have been found to be effective in reducing stigma
among youth. When offering education and contact to high school students, Spagnolo
et al (Spagnolo et al., 2008) offered an anti-stigma educational campaign to 426 US
secondary school students. The campaign included presenting accurate information
about mental illness and a real possibility of recovery. It included consumers in
preparing and presenting the information and in sharing their personal stories of
recovery. The intervention led to a decrease in stigma scores immediately post
intervention. Stuart (2006) offered videotaped sessions of a person with schizophrenia
and lesson plans for two active learning classes to 571 Canadian secondary school
students. At baseline students had high knowledge scores about schizophrenia, but poor
social distance scores, indicating that knowledge alone did not promote decreased
social distance behaviours. At post test, participants were both more knowledgeable
about schizophrenia and had better social distancing scores. Schultze (Schulze et al.,
2003) also used a program that included education and contact. However, in all cases
we do not know if the reduction continued over time.
In our study in all schools receiving the intervention, stigma did not did not decrease.
However, there was significant reduction of stigma following participation in YNFGs in
low need schools. Research studies that have demonstrated effectiveness in reducing
stigma used both educational sessions and facilitated contact with an individual with
mental health problems.
Our finding that high prosocial scores were associated with lower stigma scores merits
further investigation. The Roots of Empathy program, a generic contact strategy with a
mother and infant over a period of a year has been demonstrated to have a positive
effect on mental health of children as well as emotional and social literacy and may
affect stigma and discrimination through the promotion of social inclusion (Schachter et
al., 2007). Programs such as these could comprise a comprehensive program to
promote mental health in children and youth.
2. Research Questions 2 and 3
Helping Behaviours
Our second research question was not supported by the findings. Participants who had
lower stigma scores did not assist their peers to seek personal or professional help more
than participants with higher stigma scores. A possible reason is we used two additional
questions to the validated HSSU that did not have reliability and validity testing
suggesting that the participants may not have understood the questions as intended.
Study participants reported helping their peers seek personal help much more frequently
(30%) than professional help (7%). This has been reported by several authors and
supports normal adolescent development where teens turn to teens for support with
emotional problems (Davidson & Manion, 1996; Esters et al., 1998). Levesque and
Manion (2005) report when youth discuss mental health concerns, they talk to a friend
22
(43%), parent (23.9%), other (1.3%). About one third of youth (31.8%) do not discuss
their concerns with anyone (Canadian Psychiatric Association, 1993).
We found no literature examining the link between stigma and helping peers “who have
stress or mental health issues”. We did find four studies examining stigma and general
helping a classmate who has a mental health problem (one item on the stigma scale);
three studies found there were no changes in helping behaviors towards a classmate
with mental health problems (Corrigan, 2004b; Corrigan et al., 2007; Watson et al.,
2004); and a fourth study found an immediate post test improvement in helping
behaviours (Spagnolo et al., 2008).
The lack of available literature concerning our second research question is disappointing
as only one study was conducted with secondary school students (Spagnolo et al.,
2008). College students may have their ideas concerning helping others already set and
less malleable to change (Corrigan, 2004b; Corrigan et al., 2007; Watson et al., 2004).
Helping behaviours and the link to stigma among youth merits further investigation.
For our third research question, we did not find an interaction between participation in
YNFGs, a change in stigma scores and helping behaviours. As participants in the
YNFGs did not have significantly lower stigma scores overall, this finding is not
surprising. The link between an intervention to decrease stigma scores (an attitude) and
a change in behavior (such as increasing helping behaviors) is complex. Although it
deals with generic helping, rather than specific helping for a mental health problem, we
suggest the discussion related to research question 2 is relevant. Decreasing stigma
scores was not often associated with increased helping behaviours – as measured by an
individual item on the stigma scale at time 2.
3. Research Question 4
Help-Seeking Behaviours
Our fourth research question was not supported by study findings- willingness to seek
help [at time 2] among participants with mental health problem(s) was not associated
with participation in YNFGs. However, mental health problems in youth were higher
than previously reported findings (9.5% very elevated, 22% somewhat elevated, and
68% minimal) as compared to (Poulin et al., 2005) (5.5% very elevated, 19.5%
somewhat elevated, and 62.3% minimal). As most adult mental health problems begin
in adolescence or early adulthood, there is clear evidence of distress during
adolescence. Since less than 25% of adolescents with mental health problems receive
mental health services (Waddell et al., 2002), seeking help is a pressing need for the
adolescent population. Further, Hyman et al (2007) in a large sample of Canadian youth
who had attended Youth Net focus groups identified that females disclose twice a
frequently as males about suicidal ideation to professionals. Yet males are twice as
likely to complete suicides (Statistics Canada, 2005), therefore the development of
specialized services designed to engage male youth at risk are particularly relevant.
Elhai, Schweinle & Anderson (2008) found with college students, less treatment stigma
was positively associated with greater intentions to seek treatment.
It is challenging to compare our study findings to the literature as the intervention studies
found measured willingness to seek help for all study participants, rather than
specifically those identified as having mental health problems. As YNFGs sought to
encourage participants screened as at risk for mental health problems to seek help, we
measured the impact of the intervention specifically on participants we identified as
23
having a mental health problem (depression). In this section we offer possible reasons
for our findings and compare intervention studies to our findings.
We propose two reasons for this finding: lack of recognition of mental health problems
due to self stigma or lack of knowledge, and multiple barriers to accessing help.
Impact of Recognition of Mental Health Problems
Although we measured ‘willingness to seek care”, the literature is helpful in
understanding “care seeking” as a multi stage process and perceiving a need for
services is a key predictor of service use (Golberstein et al., 2008). Although we
identified youth as a having mental health problem, some youth may not be aware they
have problems that could be helped by professionals (Timlin-Scalera et al., 2003).
Furthermore, persons with a mental health problem may need a longer intervention than
a 1 hour YNFG in order to impact on willingness to seek care. If youth with mental
health problems have developed self stigma, this may prevent them from being willing to
seek services. Corrigan 2004b) suggests that strategies that enhance empowerment for
persons with mental illness could effectively improve help seeking behaviours.
Empowerment strategies we would suggest are currently part of the Youth Net program
as YN facilitators encourage discussion in a free and open manner that is non
judgmental and empowering to youth. It is important to address both public stigma and
self stigma in stigma reducing programs (Mental Health Commission of Canada (MHCC)
& Hotchkiss Brain Institute (HBI), 2008).
Several youth-directed anti-stigma intervention studies that examined program effects on
willingness to seek help for emotional and mental problems offer promise for middle
school students (Watson et al., 2004), and secondary school students (Esters et al.,
1998; Spagnolo et al., 2008).
In examining the literature between stigma and willingness to seek help, barriers
relevant to this study fell into 2 categories; lack of knowledge and stigma. Lack of
knowledge included a lack of awareness of resources for mental health services (Boyd
et al., 2007; Timlin-Scalera et al., 2003), unfamiliarity with mental health professionals
(Timlin-Scalera et al., 2003); decreased mental health knowledge (boys have lower
knowledge than girls), (Chandra & Minkovitz, 2007) and decreased knowledge about
effective mental health treatments (Golberstein et al., 2008).
Multiple Barriers to Accessing Help
Stigma is one of many barriers to accessing help. Stigma was experienced both
towards mental illness itself and service use (Mann & Himelein, 2004). Decreased care
seeking occurred when individuals felt responsible for their illness (Cooper et al., 2003;
Halter, 2004), felt embarrassed (Barney et al., 2005), anticipated negative responses
from family, peers, school staff (Barney et al., 2005; Chandra & Minkovitz, 2007), were
concerned about the stigma of male weakness (Moskos et al., 2007; Timlin-Scalera et
al., 2003) ,and about labeling, such as “only crazy people” use mental health services
(Boyd et al., 2007). Chandra & Minkovitch (2007) particularly identify the role of gender
and mental health stigma towards mental health service use. Boys were half as willing
to use mental health services as girls. Although 34.6% of participants had moderate to
high stigma associated with mental health service use, parental disapproval and
perceived stigma helped to explain the relationship between gender and use of mental
health services.
24
Three times (28.9% vs 9%) more boys than girls felt parental disapproval to use mental
health services. Clearly this finding addresses the need to actively involve parents to
decrease their stigma.
Other barriers for youth seeking help include; low perception of treatment success
(Corrigan, 2004b); past poor experiences; waiting lists (Moskos et al., 2007); lack of
youth friendly services (Davidson & Manion, 1996); lack of confidentiality and lack of
knowledge of services (Booth et al., 2004). Strategies that address the barriers youth
face in accessing services need to be implemented (Booth et al., 2004). Clearly, youth
willingness to seek help needs further study.
We do not have evidence from the qualitative findings about how consistently facilitators
discussed youth friendly services, thus promoting youth willingness to seek help. We
know only that the youth services guide was distributed. This is a study limitation and
could contribute to a lack of study findings about youth willingness to access to services.
4. Research Question 5
Health and Social Service Utilization
In our fifth question, we examined if there was a difference in the expenditures for Health
and Social Service Utilization (HSSU) in participants with and without mental health
problems between the YNFG participants and participants in the control group. The
finding of higher expenditures for HSSU for participants who were depressed compared
to not depressed is an expected and appropriate result. Furthermore, participants in
high need schools, both with and without mental health problems had higher HSSU
expenditures than participants in low need schools with and without mental health
problems. Byrne and colleagues (Byrne et al., 2004) surveyed youth from a socially and
emotionally disadvantaged population(compared to the surrounding neighborhood) and
found that youth with one or more emotional/behavioural problems had four times the
total expenditures for health and social services (HSSU) as youth without identified
problems. The youth in their study were particularly high users of family physician
services, public health, laboratory, emergency and hospital services. This compares to
our study results where total expenditures were higher, and participants with mental
health problems used more physician services, social work services, psychologists,
drop-in centres, police officer costs, other health professionals and outpatient tests.
The low HSSU expenditures for youth in medium need schools, yet their high mental
health problem rate is an unexplained finding.
An important finding from the qualitative data is that the youth in high need schools
expressed more negative coping strategies than the youth in low need schools. This
with the finding that high need schools proportionally required more follow ups and
referrals to community agencies reinforces that these youth, in particular, have mental
health needs that merit attention.
b. Lessons Learned
The process to build the academic-community partnership was challenged as two of our
community partner contacts left during the course of the study and were replaced by two
new members. In efforts to maintain momentum so members of the research
partnership continued their involvement in the project, we maintained communication
through email and regularly held research meetings. Each of these methods of
25
communication facilitated partnership development by providing opportunities for
discussion to problem solve challenges.
Teachers played an important role as they were responsible for communicating
information about the research project to students through distribution and collection of
consent forms. Clearly providing teachers with incentives was not a sufficient strategy to
ensure their commitment to the project. Should the study be replicated, we would
suggest the research team would need to develop other strategies to engage teachers.
Acquiring parental consent prior to youth consenting to participate in this research
project was a barrier in recruiting participants into the study. The Youth Net Hamilton
Coalition experienced a similar barrier as the HWDSB initially required parental consent
before students could participate in the program. Hamilton Public Health worked with
the HWDSB to eliminate this requirement which greatly improved participation rates.
While the academic-research partnership recognizes the importance of ethical protocols
that protect the public, it would be helpful to explore with other researchers options to
overcome this barrier. We would recommend that CHEO lead discussions with others to
develop potential solutions.
Throughout the entire process, the team met and shared research findings to build
mutual understanding so that appropriate recommendations could be formulated.
c. Implications for Policy and Practice
Informed by the research findings, review of the literature and community partners
involved in this research project, we have developed practice recommendations for the
program as currently delivered. We propose continuing the YNFGs as is in low need
schools; however as our research findings do not clearly show that there is consistent
discussion with group participants about the need to seek help from mental health
services and when someone should do so, we recommend that this component of the
program be strengthened. It is clear that services need to be as accessible and as nonthreatening as possible for youth so they are comfortable using them when need
(Hyman et al., 2007). The opportunity for students to participate in youth facilitated
sessions without a teacher present creates an environment of confidentiality, promoting
open discussions about stress, coping and help seeking (Davidson et al., 2006b;
Davidson et al., 2006a). This safe environment is a significant opportunity for youth
friendly services to be discussed and promoted. As one of the program goals is to
improve willingness to seek help, we will refocus the sharing of youth friendly mental
health services with participants during the YNFG to ensure program consistency with a
goal to improve youth help seeking behaviours.
As resources to develop and deliver prevention programs in schools are scarce and
therefore, need to be allocated appropriately where they will have the greatest impact,
we recommend a second session using a contact component or interactive component
should be added to medium and high need schools. Other Youth Net sites deliver their
program with two sessions (session 1 structured interactive games; session 2 facilitated
discussion) and have found that youth report that they had a better understanding of
mental health (Davidson et al., 2006b). As interactive programs that involve participants
in a variety of activities are most effective to address child mental health issues,
including a second session should be further explored (Browne et al., 2004).
26
A multifaceted approach with universal programs and targeted preventive interventions
for children at risk have been widely suggested in the literature and leads us to propose
further program changes for high need schools (Waddell et al., 2002; Wells et al., 2003).
The two high need schools included in the study had very different groups of students as
one school had a diverse multicultural population and was located in the inner city and
the other had students who faced greater academic challenges. In studies of stigma and
ethnicity, Corrigan found non-Caucasians are less likely to recognize the medical system
is a resource for mental health treatment (Corrigan, 2004b).Other Youth Net sites
(Davidson et al., 2006b) have used other program components as targeted strategies in
tandem with focus groups which are universal. As these targeted programs are not
offered in Hamilton, they were not included as part of this study. Although youth in high
need schools expressed more negative coping strategies, more mental health problems
and have higher socio demographic challenges, we don’t fully understand the mental
health needs of youth at these schools and further information needs to be gathered.
The other Youth Net program components could then be considered for implementation
in high need schools and then evaluated as to their impact.
All of the program changes discussed above require pilot testing and evaluation to
ensure that the addition of the second session is evidence based and effective prior to
implementation in all schools (Herrman et al., 2005).
Effective mental health promotion programs must appeal to and engage young people
and therefore including the target population when designing a program is
recommended for two purposes, to ensure that the program is relevant and to empower
participants (Davidson et al., 2006a; Rowling, 2007). Currently, Youth Net Hamilton
program has a Youth Advisory Team comprised of high school youth who participate in
youth run projects facilitated by one of our program staff. We propose that this youth
structure be revised to provide direct input into the program through a youth governance
structure.
While the focus of this study was to evaluate the effectiveness of Youth Net on mental
health stigma, the program is delivered within schools and involves the broader
community, therefore the program’s impact on schools and systems should be
considered particularly since programs that affect the social environments for children
are more effective (Browne et al., 2004; Wells et al., 2003). In Ontario, the Ministry of
Child and Youth Services and the Ministry of Education have funded school boards to
develop partnerships with local mental health services so that strategies to better meet
the mental health needs of children and youth are developed. This initiative provides us
with an excellent opportunity to influence service planning at a local level to emphasize
the importance of a broad range of programs and services, ensure that prevention
efforts are included within the strategy and that youth participate in planning. As Youth
Net Hamilton has been invited to participate in this initiative, we hope to share our
research findings with this group.
As our evidence is preliminary, we do not see policy recommendations evolving at this
time.
27
d. Study Limitations
The 54% overall participation rate, although similar to some other studies with mental
health interventions (Corrigan et al., 2005b; Pitre et al., 2007), leads us to be cautious in
generalizing the study findings.
The range of scores for the stigma scale was limited and this may have affected our
ability to find differences. There are no norms for the stigma score completed as yet
(personal communication, P. Corrigan September 30, 2008). Although we used a
reliable and valid tool to measure mental health problems, we may have identified false
positive cases by choosing a cut off of 12 or more on the mental health scale. It would
be more conservative to choose 21 or greater. We would identify fewer problems, but
more significant problems that would require help.
The individual items addressing peers helping peers were not validated and thus our
study findings are guarded. In addition, as we only measured a change in help seeking
behaviours for youth with mental health problems, we do not know if the program
changes help seeking behaviours by youth without mental health problems.
It would have been advantageous to audio record the focus groups to get a better
understanding of the discussions that took place during YNFGs as there were qualitative
data missing from the facilitator recording forms.
Youth Net Hamilton does not appear to engage youth as actively in all aspects of
program development and implementation as Youth Net Ottawa (Davidson et al.,
2006b), thus study findings must be guarded when comparing to other Youth Net sites.
e. Next Steps
The program co-ordinator meets monthly with FGF’s to provide ongoing training. This
meeting will be used to discuss more fully how facilitators distribute the youth service
guide and discuss accessing services. We will work with facilitators to determine a
consistent approach to discuss this topic with youth.
As program changes require the approval of the HWDSB, study findings including
recommendations for the program as is and proposed changes for medium and high
need schools will be presented at a Board Liaison Committee meeting. Following
approval, a process to move forward with changes will then be developed focused on
adding a second session and additional program components. Resources to conduct
evaluation will also need to be sought.
Further, since the program is delivered in partnership with Coalition members, the
findings will first be presented at an upcoming annual Coalition planning meeting. All
coalition members are involved in providing services to youth, they are a good group to
discuss youth engagement strategies and how best to move this agenda forward within
the community. To ensure that the program continues to be informed by youth, we will
work with youth to develop and implement a youth governance structure. The new
governance structure for Youth Net is to reflect a true partnership with youth and adults.
28
We will share research findings with the youth mental health planning table and
advocate for youth involvement in planning the youth mental health service delivery
model.
Nationally, Youth Net sites across Canada (seven current, four developing) are awaiting
the dissemination of these research findings to inform their programming. All Youth Net
sites meet on a regular basis through teleconference to discuss program issues and
approaches to build consistency in program delivery appropriate to the local context.
Although that data collected about focus group participants is collated, no other site has
attempted to evaluate program effectiveness.
Research next steps:
1. Replicate current study
2. Pilot test the revised approach to YN for medium and high need schools
3. Investigate the impact of YNFGs on students in community settings
4. Consider a qualitative study to learn about the processes that occur during
YNFGs.
5. As stigma scores worsened for students in grade 10, especially males, it would
be interesting to further explore these differences.
5. Conclusions
Canadian adolescents are experiencing significant amounts of mental distress -an
estimated 15% to 25% have a mental illness (Health Canada, 2002; Waddell et al.,
2002). Furthermore, youth appear reluctant to seek out formal mental health services
(Booth et al., 2004; Davidson & Manion, 1996). As stigma may be preventing youth from
seeking services, it is important to implement and evaluate anti stigma programs for
youth.
Worldwide there is emerging knowledge on mental illness stigma with groups seeking to
understand the associated elements that prevent individuals from seeking help for
mental health issues. Within the Canadian context, the Mental Health Commission of
Canada (MHCC) proposes to eliminate stigma and reduce discrimination through a
national framework for mental health and highlights the importance of youth focused
strategies (Martin & Johnston, 2007). Youth specific strategies are vital as adolescents
are more at risk for mental health disorders; therefore assisting them to seek help
sooner could greatly contribute to improved mental health outcomes (Adlaf et al., 2005;
Martin & Johnston, 2007). Our study findings add to the paucity of research evidence
about reducing stigma in Canadian youth using a specified health promotion approach,
Youth Net focus groups. However our study finding must be guarded due to study
limitations.
Study findings together with reviewed literature clearly indicate that anti-stigma programs
for adolescents are an important area to pursue. Providing youth facilitated discussions
so that adolescents can openly express their ideas about mental health, mental illness,
stress and coping resulted in decreased stigma in low need schools. However, we did
not see the same effect for medium and high need schools. The literature suggests that
interactive strategies that challenge myths concerning mental illness and facilitate
contact with someone who has a mental illness and has experienced successful
29
treatment reduce stigma (Martin & Johnston, 2007). Enhancing the YNFG program with
these components for medium and high need schools should be further explored. Given
the finding that youth in high need schools had more mental health problems, a multiple
component strategy is recommended.
Our study did not find a change in reported helping behaviours towards others or a
change in help seeking behaviours (for youth with mental health issues) following
participation in facilitated discussions. While research suggests that stigma about
mental health issues may in fact affect health seeking behaviours, youth are a
population that don’t tend to seek help from formal supports for any health issues for a
number of reasons (Barney et al., 2005; Booth et al., 2004; Chandra & Minkovitz, 2007;
Davidson & Manion, 1996; Moskos et al., 2007; Timlin-Scalera et al., 2003).
Confidentiality, familiarity, knowledge of services and discomfort of disclosing health
concerns may also need to be addressed together with reducing stigma to see an
increase in help seeking behaviours. To increase effectiveness youth should be
consulted and engaged by service providers in the development of these programs and
services.
To improve mental health outcomes for youth, just a focus on decreasing stigma in youth
is not enough. Corrigan, Kerr & Knudsen (Corrigan et al., 2005a) identify the processes
that give rise to stigma as occurring at the individual and societal level. Thus
interventions need to occur at various levels to effect change (Martin & Johnston, 2007).
As mental health stigma is affected by the context of youth’s lives, comprehensive
strategies using a health promotion framework that impacts on school climate with the
involvement of teachers and parents need to be implemented (Adlaf et al., 2005).
The Report from The Kirby Commission is an important document that brings to light the
serious problems of mental illness in Canada and makes recommendations to transform
services (Kirby & Keon, 2006). However, the focus of the report is on adults with serious
mental illness and little attention is given to children and youth with mental health
problems. Increasing services is important, but is limited as it is a ‘downstream
approach’ to treating those who are already identified as having mental health problems.
We believe it is important to take an ‘upstream approach’ to support emotional and
social well being in children and prevent mental illness in children and youth by
influencing the determinants of social and emotional well being in children (Willms,
2002). There is mounting research evidence that childhood is an optimal time for
‘upstream’ interventions which would both enhance positive well being and prevent
specific mental health problems (McEwan et al., 2007). We support a national strategy
to promote children and youth mental health rather than simply enhance services or
increase dosage.
As community partners, we agree with a public health strategy for children’s mental
health that Waddell and colleagues identified as including the promotion of healthy
development for all development for all children; preventing disorders for children at risk;
and providing treatment for children with disorders (Waddell et al., 2007). There is
growing evidence of the effectiveness of promoting healthy development for all children
(Licence, 2004; Maxwell et al., 2007; Tennant et al., 2007; Wells et al., 2003). Positive
evidence of effectiveness was obtained for programs that adopted a whole school
approach and were implemented continuously for more than one year. Programs that
involve changes to the school climate are more likely to be successful than brief class
based mental illness prevention programs (Wells et al., 2003). Durlak & Wells (1997),
30
using meta analysis reviewed 177 primary prevention studies in normal populations and
found programs that modified the school environment, individually focused mental health
promotion efforts, and attempted to help children negotiate stressful transitions yielded
significant benefits. Many reviewed programs both reduced problems and increased
competences.
The recent creation of the Mental Health Commission of Canada further advances the
issue of mental health and illness in Canada with it’s first goal to a develop a national
mental health strategy. Secondly they will combat stigma and discrimination by
supporting a 10 year anti stigma and discrimination reduction campaign (Mental Health
Commission of Canada (MHCC) & Hotchkiss Brain Institute (HBI), 2008). They have
identified youth as a priority target for the first year. We see Youth Net as contributing to
this campaign by increasing mental health awareness, decreasing stigma and improving
access to youth friendly services for secondary students. Furthermore, It could be part
of an overall school program where mental health is addressed in the curriculum from an
early age and increasingly dealt with as children change cognitively and behaviourally.
Youth Net seeks to affect adolescent mental health positively by increasing awareness
of mental health and mental illness in all adolescents by decreasing the stigma
associated with mental illness that may prevent them from seeking appropriate services.
Clearly Youth Net needs to work within a constellation of services offering health
promotion and mental illness prevention strategies as identified above.
The recommendations proposed do suggest changes to how the program is currently
delivered. We believe the changes proposed for the current program as well as the
youth governance model could be implemented and sustained. Once program
enhancements are developed and evaluated, we will explore potential finding sources so
that these changes can be implemented.
6. Knowledge Exchange Plan
As the research findings are new to the research group, the knowledge exchange plan is
in its preliminary stages of development. We have committed to the following activities
and will explore others once the research team meets again to review and discuss this
report in full.
Activity
Disseminate
report to
program staff
for discussion
Disseminate
report Youth
Net Hamilton
Steering
Committee
Target
audience
Focus Group
Facilitators
Youth Advisor
Youth Net
Co-ordinator
Alternatives
for Youth
HWDSB
Contact
Hamilton
Youth
Number of
participants
30
7
Tasks
Outcome
Review report and
develop program
recommendations
Develop
recommendations
for program
changes
Prepare
presentation
Hold steering
committee
meeting
Input into
recommendation
development
31
Activity
Present
findings to
Public Health
Services
School
Program Staff
Present
findings to
Youth Mental
Health
Workgroup
Media release
Disseminate
findings to
other Youth
Net sites
Target
audience
School Public
Health
Nurses
Number of
participants
25
Child and
Youth mental
health
treatment
services
General
public
Youth Net
sites across
Canada
20
50
Website
General
public
Unknown at
this time
Present
findings at
Peer-reviewed
conferences
Academics
Program
managers
Front line
staff
Academics
Program
managers
Front line
staff
Unknown at
this time
Present
findings
through
articles written
for peer
reviewed
journal
publications
Unknown at
this time
Tasks
Prepare
presentation
Presentation and
confirm meeting
date
Outcome
Workgroup
established to
Identify potential
strategies to
address gaps for
youth in medium
and high need
schools
Inform strategy
currently
underway
Determine key
messages
Apply for funding
so meeting can be
held to share
results and
develop
recommendations
Information is
written in a format
appropriate for
general population
Write and submit
abstracts
Raise awareness
Write and submit
abstracts and
journal articles
Inform practice
Consistent
approach
developed across
country sensitive
to local context.
Raise awareness
Inform practice
32
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40
8. Appendix
Youth Net Hamilton
Focus Group Study
Time 1 Questionnaires
Participant ID:
School ID:
Data Collector: _____________________________
Group:
Date:
Year
Month
Day
41
Questionnaire #1
Background Questions
We have some short personal questions for you.
1. What is your birth date?
Year
Month
Day
2. What grade are you currently in?
1
Grade 9
2
Grade 10
3. What is your gender?
_____________________
4. In which country were your biological or birth parents born?
a. Mother:
1 In
Canada.
2
Outside of Canada. Where? ______________
3
Don’t know
b. Father:
1 In
Canada.
2
Outside of Canada. Where? ______________
3
Don’t know
5. In which country were you born?
1 In
Canada.
2
Outside of Canada. Where? ______________
3
Don’t know
42
Questionnaire #2
Please read the following statement about Charlie.
Charlie is a new student in your class. Before Charlie’s first day, your teacher explained that Charlie is
mentally ill and is transferring from a special school.
NOW CIRCLE THE NUMBER OF THE BEST ANSWER TO EACH QUESTION.
1. I would feel pity for Charlie.
1
Not at all
2
3
4
5
6
7
8
9
Very much
4
5
6
7
8
9
Very much
4
5
6
7
8
9
Very much
6
7
8
9
Yes, absolutely so
2. How dangerous would you feel Charlie is?
1
Not at all
2
3
3. How scared of Charlie would you feel?
1
Not at all
2
3
4. I think Charlie is to blame for the mental illness.
1
2
No, not at all
3
4
5
5. I think Charlie should be in a special class for kids with problems, not a normal class like mine.
1
Not at all
2
3
4
5
6
7
8
9
Very much
4
5
6
7
8
6
7
8
9
Definitely
would help
6
7
8
9
Very much
6. How angry would you feel at Charlie?
1
Not at all
2
3
9
Very much
7. How likely is it that you would help Charlie with school work?
1
2
Definitely would
not help
3
4
5
8. I would try to stay away from Charlie after school.
1
Not at all
2
3
4
5
Imagine you were feeling depressed and having some problems at home. A month later, you were
still having difficulties and find yourself crying all the time, unable to sleep much, and unable to
pay attention at school.
9. Would you be willing to see a counselor or doctor to get help with your depression?
1
Definitely
would not
2
3
4
5
6
7
8
9
Definitely
would
43
Questionnaire #3
Feelings and Behaviours During the Past Week
The next set of statements describe feelings or behaviours. For each one, please tell me how
often you felt or behaved this way during the past week.
How often have you felt or behaved
this way during the past week?
a. I did not feel like eating; my
appetite was poor.
b. I felt that I could not shake off
the blues even with help from
my family or friends.
c. I had trouble keeping my mind
on what I was doing.
d. I felt depressed.
e. I felt that everything I did was an
effort.
f. I felt hopeful about the future.
g. My sleep was restless.
h. I was happy.
i. I felt lonely.
j. I enjoyed life.
k. I had crying spells.
l. I felt that people disliked me.
Rarely or none
of the time
(less than 1
day)
Some or a little
of the time (1-2
days)
Occasionally
or a moderate
amount of time
(3-4 days)
Most or all of
the time (5-7
days)
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
1
2
3
4
44
Questionnaire #4
Feelings and Behaviours That Best Describe You
Please read the following statements and choose
the answer that best describes you.
a.
I show sympathy to (I feel sorry for) someone who
has made a mistake.
b.
I can’t sit still, I am restless.
c.
I destroy my own things.
d.
I try to help someone who has been hurt.
e.
I steal at home.
f.
I am unhappy or sad.
g.
I get into many fights.
h.
I offer to help clear up a mess someone else has
made.
i.
I am easily distracted. I have trouble sticking to my
activity.
j.
When I am mad at someone, I try to get others to
dislike him/her.
k.
I am not as happy as other people my age.
l.
I destroy things belonging to my family or other
young people.
m. If there is an argument, I try to stop it.
n.
I can’t concentrate, I can’t pay attention.
o.
I am too fearful or nervous.
Never or not
true
Sometimes or
somewhat true
Often or
very true
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
45
Please read the following statements and choose
the answer that best describes you.
p.
When I am mad at someone, I become friends with
another as revenge.
q.
I am impulsive; I act without thinking.
r.
I tell lies or cheat.
s.
I offer to help other young people (friend, brother or
sister) who are having difficulty with a task.
t.
I worry a lot.
u.
I have difficulty waiting for my turn in games or
group activities.
v.
When another young person accidentally hurts me,
I assume that he/she meant to do it, and I react
with anger and fighting.
w.
When I am mad at someone, I say bad things
behind his/her back.
x.
I physically attack people.
y.
I comfort another young person (friend, brother or
sister) who is crying or upset.
z.
I cry a lot.
aa. I vandalize.
bb. I threaten people.
cc. I help to pick up things which another young person
has dropped.
dd. I bully or am mean to others.
ee. I stare into space.
Never or not
true
Sometimes or
somewhat true
Often or
very true
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
46
Please read the following statements and choose
the answer that best describes you.
ff.
When I am mad at someone, I say to others: let’s
not be with him/her.
gg. I am nervous, high-strung or tense.
hh. I kick or hit other people my age.
ii.
When I am playing with others, I invite bystanders
to join in a game.
jj.
I steal outside my home.
kk. I have difficulty paying attention to someone.
ll.
I have trouble enjoying myself.
mm. I help other people my age (friends, brother or
sister) who are feeling sick.
nn. When I am mad at someone, I tell that person’s
secrets to a third person.
oo. I encourage other people my age who cannot do
things as well as I can.
Never or not
true
Sometimes or
somewhat true
Often or
very true
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
1
2
3
47
Questionnaire #5
Health and Social Service Utilization
PART A
1. In the last 2 weeks, how many visits have you had with a(n):
Family
Physician/Walk-in
Clinic
Physician
specialist
‰‰ visits
‰‰ visits
Emergency Room
‰‰ visits
Call 911
Ambulance
‰‰ visits
‰‰ visits
PART B
2. Have you seen any other health and/or social service providers in the last 2 weeks?
Physiotherapist
Social Worker
Adolescent/
School Counsellor
Children’s Aid
Family Counsellor
‰‰ visits
Occupational
Therapist
‰‰ visits
Psychologist
‰‰ visits
Psychiatrist
‰‰ visits
Visiting Nurse (e.g.
‰‰ visits
‰‰ visits
Drop-in Centre
‰‰ visits
Chiropractor
VON, SEN, Para-med,
Home Care, Public
Health)
Police
Officer/Parole
Officer
‰‰ visits
‰‰ visits
‰‰ visits
Support Group
‰‰ visits
Others
Others
(specify)
(specify)
(specify)
‰‰ visits
‰‰ visits
‰‰ visits
‰‰ visits
3. Have you stayed in a shelter (e.g. homeless) in the past 6 months?
‰1 Yes
Î
19 a.
Total number of shelter admission(s) in the past 6 months?
Admissions
19b.
Total number of days in the shelter in the past 6 months?
Days
‰2 No Î Go to Question 4
48
4. Have you had a hospital admission in the past 6 months?
‰1 Yes
Î
20 a.
Total number of hospital admission(s) in the past 6 months?
Admissions
20b.
Total number of days in the hospital in the past 6 months?
Days
‰2 No Î Go to Question 5
. 5.
Have you had any out-patient tests done in the past 2 weeks?
‰1 Yes Î See table below
‰ 2 No Î Go to Question 6
If yes, please tell me how many times for each of the following tests.
# of times
a.
Blood
_______
b.
Specimens (i.e., urine, throat swab)
_______
c.
Scopes (.i.e. endoscopy, bronchoscopy, sigmoidoscopy)
_______
d.
X-rays
_______
e.
Scans (i.e., ultrasound, CT scan)
_______
f
Other tests: Please specify
_______
6. Have you taken any medications over the past 2 days?
‰1 Yes
‰2 No Î Go to Question 7
If yes, please list any medication that you have taken in the past 2 days (including prescription and nonprescription medication). Or, if you don’t remember the name of the medication, put the reason you are
taking the medication (e.g., ADD, depression, anxiety, etc.).
Name of medication
taken in the last 2 days
Dose (mg)
# pills each time (pills
per dose)
#Times each day (doses
per day)
1.
2.
3.
4.
5.
49
7.
In the last month, have you tried to be supportive to a friend or classmate who is
suffering from stress or other mental health issues?
# of times
______________
‰1 Yes Î if yes, please describe:
________________________________________________________
‰2
‰3
8.
No
Not applicable
In the last month, have you assisted a friend or classmate to seek professional
help (such as, for example, from a doctor, counsellor, or nurse) for stress or other
mental health issues?
# of times
______________
‰1 Yes Î if yes, please describe:
________________________________________________________
‰2
‰3
No
Not applicable
Thank-you for completing these questionnaires
50
CODE: _________
YOUTH NET HAMILTON
Focus Group Recording Form
A.
Focus Group Information
Date:
Time:
Month
Day
Language:
Year
Focus Group Facilitators:
Location:
B.
Contact Person:
Participants
Total Number of Participants:
C.
&
Number of Males:
Number of Females:
Focus Group Summary
1. a) What were the main ideas presented by participants about mental health?
1. b) What was the main response (process) of the facilitator(s)?
2. a) What were the main ideas presented by participants about mental illness?
2. b) What was the main response (process) of the facilitator(s)?
3. a) What were the main ideas presented by participants about causes of stress?
51
3. b) What was the main response (process) of the facilitator(s)?
4. a) What were the main ideas presented by participants about coping with stress?
4. b) What was the main response (process) of the facilitator(s)?
5. What were the two most important ideas or main themes of the focus group?
D.
Follow-ups, Recommended Services, and Referrals
Total # of Follow-ups:
# of COAST referrals
# of Female Follow-ups:
# of Male Follow-ups:
# of COAST alerts (FYI):
# of On-site referrals (i.e. in
Specify professions:
# of Community referrals:
Specify agencies:
# of Supports
Specify supports:
Signature of facilitator completing this form
Signature of facilitator reviewing this form
52
Figure 1
Male: (n=251)
Female: (n=295)
Total number of youth that are in the
24 classes which participated
(potential participants)
(n=546)
Returned signed Parent Consent
and Youth Assent forms
(n=327)
Not participating (n=219)
•
Did not return consent
(n=200)
•
Duplicate (student
already participated in
Semester 1) (n=3)
•
Returned unsigned
consent (n=15)
•
Student no longer in
class (n=1)
Did not participate (n=33)
•
Absent the day of
data collection (n=31)
•
Duplicate (student
already participated in
Semester 1 (n=2)
R
n=294
Male: (n=75)
Female: (n=62)
Control Group
(n=137)
12 classes:
• 6 Grade 9 classes
• 6 Grade 10 classes
Lost to
Follow-up
Male: (n=71)
Female: (n=55)
Time 2: Number of
Participants
(n=126)
Male: (n=52)
Female: (n=105)
•
Absent (n=11)
Male: (n=45)
Female: (n=97)
Total Participants at
Time 2 (n=268)
Intervention Group
(n=157)
12 classes:
• 11 Grade 9 classes
• 1 Grade 10 class
Lost to
Follow-up
•
•
Absent (n=14)
Suspended
(n=1)
Time 2: Number of
Participants
(n=142)
53
Appendices Tables
Table 1: Descriptive data of Schools and Study Participants in the Youth Net Study
School
#
#
Students Participated
Study
Completed
Status
School Classrooms
Eligible
Drop outs
s
Low
2
7
175
113 ( 65%)
10 (9%)
103 (91%)
needs*
Medium 2
8
202
106 (52%)
8 (8%)
98 (92 %)
needs*
High
2
9
169
75 (44%)
8 (11%)
67 (89 %)
needs*
Total
6
24
546
294 (54%)
26 (9%)
268 (91%)
* As defined by the Hamilton-Wentworth District School Board
Table 2: Representativeness: A comparison of the rate of study participation non
participation and gender
Potential study
546
Male
Female
participants
Study Participants
294 (54%)
127 (43%)
167 (57%)
Non Consenters
252 (46%)
124 (49%)
128 (51%)
Total
546 (100%)
251 (46%)
295 (54%)
Table 3: Comparison of study participants to study drop outs by gender
Students
Total
Male
Female
Study Participants
Study Drop outs
268 ( 91% of 294))
26 (9% of 294)
116 (91% of 127)
11 (9% of 127)
152 (91% of 167)
15 (9% of 167)
54
Table 4: Comparison of Demographic Variables in the Control Group and the Intervention
Group at Baseline
Total
n
1 Control
group
%
n
%
2
Intervention
group
n
%
Test Statistics
Chisquare
p-values
1. What is your age?
13
6
2
1
0.7
5
3.2 13.751
.056 (a,b)
14
166
56.5
67
48.9
99
63.1
15
86
29.3
50
36.5
36
22.9
16
20
6.8
13
9.5
7
4.5
17
6
2
3
2.2
3
1.9
18
5
1.7
1
0.7
4
2.5
19
3
1
1
0.7
2
1.3
20
2
0.7
1
0.7
1
0.6
Total
294
100
137
100
157
100
2. What grade are you currently in?
Grade 9
229
79
88
64.7
141
91.6 31.352
.000(*)
Grade 10
61
21
48
35.3
13
8.4
Not stated
4
1
3
Total
290
100
137
100
157
100
3. What is your gender?
Male
127
43.2
75
54.7
52
33.1 13.941
.000(*)
Female
167
56.8
62
45.3
105
66.9
Total
294
100
137
100
157
100
4a. In which country was your biological or birth mother born?
In Canada
211
71.8
97
70.8
114
72.6 1.005
.605(a)
Outside
77
26.2
36
26.3
41
26.1
Canada
Don't know
6
2
4
2.9
2
1.3
Total
294
100
137
100
157
100
4b. In which country was your biological or birth father born?
In Canada
191
65
85
62
106
67.5 1.341
0.511
Outside
89
30.3
46
33.6
43
27.4
Canada
Don't know
14
4.8
6
4.4
8
5.1
Total
294
100
137
100
157
100
5. In which country were you born?
In Canada
254
86.4
115
83.9
139
88.5 3.026
.220 (a,b)
Outside
38
12.9
20
14.6
18
11.5
Canada
Don't know
2
0.7
2
1.5
Total
294
100
137
100
157
100
Results are based on nonempty rows and columns in each innermost sub-table.
*
The Chi-square statistic is significant at the 0.05 level.
A
More than 20% of cells in this sub-table have expected cell counts less than 5. Chisquare results may be invalid.
B
The minimum expected cell count in this sub-table is less than one. Chi-square results
may be invalid.
55
Table 5 Comparison of control group and intervention group on study questionnaires: stigma,
mental health, & feelings & behaviours
Control group
Intervention group
Total (N=294)
Test Statistics
(N=137)
(N=157)
Mean
S.D.
Mean
S.D.
Mean
S.D.
t-test
p-values
Age
14.63
1.072
14.72
0.998
14.55
1.129
1.398
0.163
Stigma
1. I would feel pity for
5.7
2.12
5.58
2.03
5.82
2.19
-0.964
0.336
Charlie.
2. How dangerous
would you feel
2.94
1.93
2.88
1.85
2.99
2
-0.461
0.645
Charlie is?
3. How scared of
Charlie would you
2.42
1.86
2.49
1.93
2.36
1.8
0.578
0.564
feel?
4. I think Charlie is to
blame for the mental
1.32
1.02
1.34
0.96
1.30
1.08
0.303
0.762
illness.
5. I think Charlie
should be in a special
class for kids with
problems, not a
normal class like
3.66
2.37
3.76
2.39
3.57
2.36
0.692
0.490
mine
6. How angry would
1.52
1.23
1.44
1.12
1.59
1.32
-1.029
0.304
you feel at Charlie?
7. How likely is it that
you would help
Charlie with school
5.7
2.42
5.76
2.41
5.65
2.44
0.386
0.700
work
8. I would try to stay
away from Charlie
3.46
2.19
3.42
2.11
3.50
2.25
-0.340
0.734
after school
Stigma (total score)
15.91
8.15
15.99
7.6
15.84
8.62
0.152
0.880
0-64
Willingness to seek help
9. Would you be
willing to see a
counselor or doctor
to get help with your
depression?
5.14
2.71
5.33
2.73
4.98
2.7
1.096
0.274
Depression score (0-36)
Depression score
9.95
6.74
10.04
7.45
9.86
6.07
0.227
0.820
Feeling and Behaviours
Hyperactivity/Inattren
tion Score (0-12) high score indicate
the presence of
hyperactive/inattentiv
e behaviour
4.42
2.63
4.42
2.66
4.42
2.62
-0.014
0.989
56
Pro-social score (020), a high score
indicating presence
of prosocial
behaviour
Anxiety and
Emotional Disorder
Score (0-14), a high
score indicating the
presence of
behaviours
associated with
anxiety and
emotional disorder
Conduct
Disorder/Physical
Aggression Score (012), a high score
indicating behaviours
associated with
conduct disorders
and physical
aggression
Indirect Agression
Score (0-10),a high
score indicating
behaviour associated
with indirect
aggression
Property Offence
Score (0-12), a high
score indicating be
12.32
3.69
12.58
3.51
12.1
3.85
1.100
0.272
3.91
3.24
3.72
3.42
4.09
3.09
-0.985
0.325
1.49
1.96
1.66
2.13
1.34
1.8
1.366
0.173
1.4
1.56
1.37
1.71
1.42
1.41
-0.264
0.792
h2.25
1.47
2.28
1.5
2.22
1.44
0.396
0.692
Table 6: Presence of Mental Health Problems at Baseline in the Control and Intervention
Groups as measured by Depression scores
Group
Severe (21-36)
Moderate (12-20)
No mental health
problem (0-11)
Total
Control
16 (11.6% of 137)
27 (19.7%)
94 (68.6%)
Focus Group
12 (7.6% of 157)
39 (24.8%)
106 (67.5%)
Total %
28 (9.5%)
66 (22%)
200 (68%)
137
157
294 (100%)
57
Table 7 : Presence of Mental Health Problems at Baseline for all study participants: As
measured by Depression scores and by school status (low, medium, high needs)
Mental Health
School Status
Problems
Low
Medium
High
Total
Severe (21-36)
6 (5.3% of
13 (12.3% of
9 (12% of 75) 28 (9.5% of
113)
106)
294)
Moderate (12-20) 20 (17.7%)
No mental health 87 (77.0%)
problem (0-11)
Total
113
χ2 12.15, df =4, p.02
21 (19.8%)
72 (67.9%)
25 (33.3%)
41 (54.7%)
66 (22.4%)
200 (68.0%)
106
75
294
Table 8 : For Study Completers: Presence of Mental Health Problems at Baseline as
measured by Depression scores and by school status (low, medium, high needs)
Mental Health
School Status
Problems
Low
Medium
High
Total
Severe (21-36)
4 (3.8% of
11(11.2% of 98) 8 (11.9% of
23 (8.6% of
103)
67)
268)
Moderate (12-20) 20 (19.4%)
No mental health 79 (76.7.0%)
problem (0-11)
Total
103
χ2 11.96, df =2, p.02
20(20.4%)
67 (68.4%)
25 (34.3%)
36 (53.7%)
63 (23.5%)
182 (67.9%)
98
67
268
58
Table 9 Mean cost of Health and Social Utilization Services in the last 6 months (Baseline)
Total
Control
Intervention
Kruskal-Wallis
59
Table 10: Mean cost of 6-Month Health and Social Utilization for those completers versus Drop
outs
Total (N=294)
Mean
Primary Care
Family Physician/Walkin Clinic
(Primary care)
145.65
Physician specialists
95.83
Emergency Room visits
148.9
911 calls
9.15
Ambulance Service
63.67
Health and Social Service Providers
Physiotherapist
80.69
Social Worker
76.04
Adolescent/School Counsellor
72.52
Children's Aid worker visit'
34.14
Family Counsellor
79.38
Occupational Therapist
4.63
Psychiatrist
2.85
Visiting nurse
35.85
Chiropractor
31.11
Drop-in center
1.33
Police Officer/Parole Officer
45.69
Other Health/Social
Professionals
133.38
Outpatient lab tests
Outpatient lab tests in last 6
month cost
207.63
a. Blood
32.92
b. Specimens (i.e., urine, throat
swab)
5.45
c. Scopes (i.e., endoscopy,
bronchoscopy, sigmoidoscopy)
20.59
d. X-rays
59.96
e. Scans (i.e., ultrasound, CT
scan)
69.41
f. Other lab test
19.29
Medication
Medication cost
99.12
Total
Direct cost excluding hosptial
in last 6 months
1367.6
Hospital cost in last 6 months
212.2
Direct cost including hospital in
last 6 months
1579.8
S.D.
Completed the
study (N=268)
Mean
S.D.
785.63 147.95 820.26
1008.56 105.12 1056.1
905.98 163.35 947.82
83.27
10.04
87.18
628.18
69.85 657.73
684.91
410.21
405.46
229.83
954.31
79.4
48.8
385.33
189.54
13.09
267.99
Drop out
(N=26)
Mean
S.D.
122 217.73
0
0
0
0
0
0
0
0
Kruskal Wallis
Test
ChipSquare values
1.59
0.897
1.001
0.492
0.392
0.207
0.343
0.317
0.483
0.531
88.52
71.5
64.64
37.45
87.08
0
3.12
37.14
34.13
1.46
50.13
717
384.3
349.51
240.5
999.36
0
51.12
402.1
198.29
13.7
280.34
0
122.8
153.8
0
0
52.36
0
22.52
0
0
0
0
626.36
783.97
0
0
267.01
0
114.83
0
0
0
0.897
0.003
0.001
0.795
0.392
10.308
0.097
0.133
1.104
0.293
0.898
0.343
0.953
0.978
0.373
0.531
0.001
0.755
0.716
0.293
0.588
0.343
780.82 146.32
816.8
0
0
1.961
0.161
1065.52 223.63 1114.2 42.73
141.65
34.54 146.12 16.18
128
82.53
0
0.268
0.995
0.605
7.71
39.31
0.773
0.379
262.74
323.16
22.58 275.15
0
63.95 336.98 18.84
0
96.04
0.195
0.214
0.659
0.643
560.59
260.94
76.15 586.81
21.16 273.28
0
0
0.592
0.293
0.442
0.588
312.11
97.63 314.89 114.5 287.05
0.747
0.387
3817.87 1439.1 3971.2 630.7 1335.4
1383.91 214.29 1427.8 190.7 819.93
0.003
0.073
0.958
0.788
4452.75 1653.3 4634.7 821.4 1519.6
0.012
0.914
52.09
5.24
53.22
0
0
60
Table 11 Mean cost of 6-Month Health and Social Utilization for those Study Completers with Mental Health Problems
Versus without Mental Health problems
Total (N=268)
Moderate &
Severe
No Mental
Depression (12Health problem
36) (N=86)
(0-11) (N=182)
Control (N=126)
Moderate &
No Mental
Severe
Depression (12Health problem
36) (N=40)
(0-11) (N=86)
Intervention Group (N=142)
Moderate
No Mental
&Severe
Depression (12Health problem
36) (N=46)
(0-11) (N=96)
Mean
S.D.
Mean
S.D.
Mean
S.D.
S.D.
Mean
S.D.
Mean
S.D.
Mean
Kruskal Wallis
Test
ChipSquare
values
Primary Care
Family Physician/Walk-in Clinic (Primary care)
Baseline
193.64
420.25
126.36
952.95
227.99
482.59
73.77
187.58
163.77
360.27
173.47
1301.5
10.449
0.015
1 Month Follow-up
165.98
312.89
50.11
212.71
158.6
333.55
59.94
282.13
172.39
297.33
41.3
121.76
19.017
0.000
298.69
1850.3
13.66
105.8
580.03
2688
19.27
125.62
54.04
270.75
8.63
84.57
7.653
0.054
57.81
278.2
18.21
121.82
82.86
313.99
38.54
175.52
36.03
244.35
0
0
6.649
0.084
Physician specialists
Baseline
1 Month Follow-up
Emergency Room visits
Baseline
373.3
1327.8
64.14
682.97
510.74
1303.1
101.81
944.13
253.78
1351.7
30.4
297.87
17.379
0.001
237.55
1022.3
80.18
714.97
364.81
1352.5
101.81
944.13
126.89
601.75
60.8
419.03
4.368
0.224
Baseline
6.95
45.33
11.5
101.19
7.48
47.28
17.38
132.57
6.5
44.09
6.23
61.03
0.555
0.907
1 Month Follow-up
3.48
32.24
9.86
98.9
7.48
47.28
20.86
143.51
0
0
0
0
3.412
0.332
108.84
575.83
51.43
693.81
156
688.65
108.84
1009.3
67.83
460.02
0
0
4.948
0.176
36.28
336.44
68.57
730.13
78
493.32
145.12
1060.2
0
0
0
0
3.413
0.332
Baseline
47.97
218.48
107.68
857.2
77.36
275.13
167.91
1161.1
22.42
152.07
53.72
432.96
2.705
0.439
1 Month Follow-up
71.96
469.09
39.67
251.14
154.71
682.97
47.97
269.75
0
0
32.23
234.4
4.564
0.207
Baseline
129.98
502.91
43.87
310.95
199.61
645.64
92.84
448.65
69.43
329.26
0
0
8.34
0.039
1 Month Follow-up
148.55
581.12
26.32
203.89
239.54
771.39
37.14
242.09
69.43
329.26
16.63
162.98
7.581
0.056
Baseline
92.97
491.86
51.25
256.96
166.56
687.27
92.97
341.45
28.97
196.47
13.88
136
5.705
0.127
1 Month Follow-up
92.97
397.95
36.61
294.86
99.94
466.25
46.48
319.78
86.9
332.64
27.76
272
3.815
0.282
84.88
386.57
15.04
116.5
91.25
345.76
31.83
168.41
79.35
422.6
0
0
6.137
0.105
1 Month Follow-up
911 calls
Ambulance Service
Baseline
1 Month Follow-up
Health and Social Service Providers
Physiotherapist
Social Worker
Adolescent/School Counsellor
Children's Aid worker visit
Baseline
1 Month Follow-up
Total (N=268)
Moderate &
Severe
No Mental
Depression (12Health problem
36) (N=86)
(0-11) (N=182)
Control (N=126)
Moderate &
Severe
No Mental
Depression (12Health problem
(0-11) (N=86)
36) (N=40)
Intervention Group (N=142)
Moderate
&Severe
No Mental
Depression (12Health problem
(0-11) (N=96)
36) (N=46)
Mean
Mean
Mean
S.D.
Mean
S.D.
S.D.
Mean
S.D.
S.D.
31.83
295.18
5.01
67.64
0
0
0
0
59.51
180.91
1677.7
42.74
381.15
0
0
36.18
235.86
18.09
167.77
8.55
115.33
0
0
0
0
Baseline
0
0
0
0
0
0
0
1 Month Follow-up
0
0
7.48
100.92
0
0
0
0
0
0
0
64.25
441.98
0
0
9.73
90.24
0
0
0
Baseline
20.43
1 Month Follow-up
Mean
S.D.
Kruskal Wallis
Test
ChipSquare
values
403.61
9.5
93.13
2.329
0.507
338.23
2294
48.62
476.38
1.277
0.735
33.82
229.4
16.21
158.79
2.318
0.509
0
0
0
0
0
0
1.000
15.83
146.81
0
0
0
0
2.116
0.549
0
0
0
0
0
0
0
0
1.000
138.13
644.43
0
0
0
0
0
0
11.443
0.010
0
20.92
132.31
0
0
0
0
0
0
5.7
0.127
0
0
0
0
0
0
0
0
0
0
0
1.000
108.06
45.04
482.52
14.64
92.58
13.62
88.76
25.46
120.73
73.19
659.44
0.662
0.882
27.23
198.95
9.65
96.83
43.91
277.74
13.62
126.28
12.73
86.33
6.1
59.76
0.627
0.890
Baseline
40.51
196.22
31.11
199.73
43.55
192.25
50.64
278.8
37.87
201.69
13.61
76.17
0.433
0.933
1 Month Follow-up
20.26
113.9
7.18
55.6
10.89
68.86
15.19
80.38
28.4
142.3
0
0
3.76
0.289
Baseline
3.02
19.71
0.71
9.64
6.5
28.69
1.51
14.02
0
0
0
0
7.025
0.071
1 Month Follow-up
4.53
31.2
0
0
0
0
0
0
8.48
42.48
0
0
9.688
0.021
78.11
316.21
36.91
261.59
134.34
408.16
46.86
247.94
29.2
198.08
27.99
274.22
7.099
0.069
124.97
530.52
0
0
201.51
648.93
0
0
58.41
396.15
0
0
17.808
0.000
Family Counsellor
Baseline
1 Month Follow-up
Occupational Therapist
Psychologist
Baseline
1 Month Follow-up
Psychiatrist
Baseline
1 Month Follow-up
Visiting nurse
Chiropractor
Drop-in center
Police Officer/Parole Officer
Baseline
1 Month Follow-up
Other Health/Social Service Professionals
Baseline
196.41
1153
122.66
598.39
326.04
1604
150.78
607.91
83.69
503.5
97.47
591.78
2.252
0.522
1 Month Follow-up
177.71
1412.2
51.91
325.63
382.07
2065.5
72.06
319.44
0
0
33.85
331.7
7.71
0.052
Baseline
609.33
1885.2
41.38
241.33
934.31
2396.6
69.75
339.55
326.73
1248.9
15.96
80.11
16.982
0.001
1 Month Follow-up
243.92
984.53
110.64
637.32
396.63
1411.8
199.04
895.43
111.13
254.64
31.46
207.5
12.093
0.007
Outpatient lab tests
Total (N=268)
Moderate &
Severe
No Mental
Depression (12Health problem
36) (N=86)
(0-11) (N=182)
Control (N=126)
Moderate &
Severe
No Mental
Depression (12Health problem
(0-11) (N=86)
36) (N=40)
Intervention Group (N=142)
Moderate
&Severe
No Mental
Depression (12Health problem
(0-11) (N=96)
36) (N=46)
Mean
Mean
Mean
S.D.
Mean
S.D.
S.D.
Mean
S.D.
S.D.
Mean
S.D.
Kruskal Wallis
Test
ChipSquare
values
a. Blood
Baseline
1 Month Follow-up
73.4
215.94
16.18
92.42
94.68
260.76
24.47
118.23
54.89
168.53
8.77
60.42
10.085
0.018
39.15
138.86
16.18
102.46
21.04
92.88
24.47
134.7
54.89
168.53
8.77
60.42
5.84
0.120
13.99
91.17
1.1
14.86
25.06
129.89
0
0
4.36
29.56
2.09
20.46
4.944
0.176
9.32
42.46
2.2
20.96
10.02
44.25
2.33
21.62
8.72
41.33
2.09
20.46
3.399
0.334
b. Specimens (i.e., urine, throat swab)
Baseline
1 Month Follow-up
c. Scopes (i.e., endoscopy, bronchoscopy, sigmoidoscopy)
Baseline
70.38
484.16
0
0
50.44
318.99
0
0
87.72
594.92
0
0
4.276
0.233
0
0
0
0
0
0
0
0
0
0
0
0
0
1.000
182.22
572.31
8.07
62.52
269.34
674.11
11.39
74.24
106.46
460.7
5.1
49.98
26.644
0.000
85.41
377.03
24.22
187.57
146.91
534.15
51.25
271.14
31.94
122.25
0
0
8.425
0.038
Baseline
203.4
978.81
16.02
216.1
364.42
1351
33.9
314.37
63.38
429.85
0
0
13.61
0.003
1 Month Follow-up
101.7
662.95
64.07
428.61
218.65
965.23
118.65
600.61
0
0
15.18
148.77
4.501
0.212
65.95
481.25
0
0
130.37
701.13
0
0
9.94
67.39
0
0
7.973
0.047
8.34
56.41
3.97
41.26
0
0
2.34
21.74
15.59
76.78
5.42
53.07
3.339
0.342
115.21
336.96
89.32
304.52
109.09
320.21
79.82
287.3
120.54
354.32
97.83
320.42
2.351
0.503
68.71
221.37
60.73
247.65
30.77
69.5
56.39
226.81
101.7
293.23
64.62
266.07
5.107
0.164
1 Month Follow-up
d. X-rays
Baseline
1 Month Follow-up
e. Scans (i.e., ultrasound, CT scan)
f. Other lab test
Baseline
1 Month Follow-up
Medication cost
Baseline
1 Month Follow-up
Direct cost excluding hospital in last 6 months
Direct cost excluding hospital in last 6
months
Direct cost excluding hospital in last 6
months
2590.9
5472.7
894.79
2875.8
3606.4
6698.8
1155.8
3173.4
1707.8
3996.2
660.99
2574.8
14.011
0.003
1596.1
4392.7
590.68
2616
2389.9
6109
869.98
3661.4
905.82
1748.2
340.47
953.65
18.236
0.000
Baseline
528.45
2357.4
65.83
573.19
454.47
1997.5
129.71
826.95
592.79
2651.4
8.61
84.33
10.827
0.013
1 Month Follow-up
259.42
1384.2
0
0
351.18
1860.8
0
0
179.63
777.36
0
0
14.194
0.003
Hospital cost in last 6 months
Direct cost including hospital in last 6 months
Baseline
3119.3
6532.2
960.62
3185
4060.9
7900.3
1285.5
3740.4
2300.6
5003.3
669.6
2574.5
16.604
0.001
1 Month Follow-up
1855.5
5277.6
590.68
2616
2741
7259.1
869.98
3661.4
1085.5
2374.5
340.47
953.65
18.885
0.000
Table 12: HSSU total direct expenditures a time 2 (without hospitalizations) for
study participants with and without mental health problems by school status (low,
medium and high)
Mental Health
Problems
Low
Mean
SD
1038.61 1456.99
(n=24 )
Medium
Mean
280.49
(n= 31)
SD
777.03
High
Mean
3343.23
(n=31 )
Mental health
problem (12 to
36)
No mental health
566.03 1286.85 248.19 823.58
1282.17
problem (0-11)
(n=79 )
(n=67 )
(n=36 )
N
103
98
67
Total
676.15 1336.16 258.41 805.28
2235.80
Direct costs are dependent on school status p.004
Total
Mean
SD
6873.76
5449.93
Total
1596.07
(n=86)
590.68
(n=182)
268
SD
4392.7
2615.95
6188.68
Table 13: HSSU Family physician/ walk-in clinic expenditure at time 2 for study
participants with and without mental health problems by school status (low,
medium and high)
Mental Health
Problems
Low
Mean
132.17
(n=24 )
SD
223.89
Medium
Mean
63.95
(n= 31)
SD
180.16
High
Mean
294.18
(n=31 )
SD
421.71
Mental health
problem (12 to
36)
No mental health
50.19
204.43
11.84
67.98
121.15
352.35
problem (0-11)
(n=79 )
(n=67 )
(n=36 )
N
103
98
67
Total
Family physician/walk-in clinic is dependent on school status p=.008
Total
Total
Mean
165.98
(n=86)
SD
312.89
50.11
(n=182)
268
211.71
64
Table14: HSSU Emergency room expenditures a time 2 for study participants with
and without mental health problems by school status (low, medium and high)
Mental Health
Problems
Low
Medium
Total
High
Total
Mean
Mean
SD
Mean
SD
Mean
SD
0
0
94.15
524.18
564.87
1584.14
237.55
Mental health
(n=24 )
(n= 31)
(n=31 )
(n=86)
problem (12 to
36)
No mental health
36.94
328.36
43.56
356.55
243.21
1459.25
80.18
problem (0-11)
(n=79 )
(n=67 )
(n=36 )
(n=182)
N
103
98
67
268
Total
28.33
287.57
59.56
414.77
392.04
1515.27
For emergency room expenditures ICC were marginally dependent on school status
p=.058
SD
1022.34
714.97
HSSU expenditure at time 1 is the main contributing factor affecting cost at time 2. I
would argue clinically that cost at time 1 is dependent on school status and depression
level.
Table 15: Correlations at Baseline between Feelings and Behaviours Subscales
and Total Stigma Score
Stigma Total score at Baseline
Pearson
Correlation
-0.087
Hyperactivity/In attention Score (0-12) – high
score indicate the presence of
hyperactive/inattentive behaviour
Pro-social score (0-20), a high score indicating
-.422(**)
presence of prosocial behaviour
Anxiety and Emotional Disorder Score (0-14), a
-0.021
high score indicating the presence of behaviours
associated with anxiety and emotional disorder
Anxiety and Disorder/Physical Aggression Score
0.081
(0-12), a high score indicating behaviours
associated with conduct disorders and physical
aggression
Indirect Aggression Score (0-10), a high score
0.06
indicating behaviours associated with indirect
aggression
Property Offence Score (0-12), a high score
0.04
indicating behaviours associated with property
offences
** Correlation is significant at the 0.01 level (2-tailed)
Sig. (2tailed)
0.158
N
268
0
268
0.736
268
0.184
268
0.328
268
0.51
268
65